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APPENDICITIS 

DEAVER 


BY  THE  SAME  AUTHOR 


Surgical  Anatomy 
A  Treatise  on  Human  ^Vnatomyix  its  Applica- 
tion TO  THE  Practice  of  Medicine  and  Surgery. 
With   499  Full-page  Illustrations,  engraved   from 
original   drawings,   made   by  special   artists,  from 

,  dissections  prepared  for  the  purpose  in  the  dis- 
secting rooms  of  the  University  of  Pennsylvania. 
Three  Royal  Square  Octavo  Volumes. 

Half  Morocco,  $30.00 


Surgical  Anatomy  of  the  Head  and  Neck 

With  177  Full-page  Plates,  nearly  all  of  which  have 

been  made  from  special  dissections.    Royal  Octavo. 

Half  Morocco,  Si 2. 00 


Enlargement  of  the  Prostate 

Its  History,  Anatomy,  Pathology,  Causes, 
Symptoms,  Diagnosis,  Treatment,  and  Tech- 
Nic  of  Operations.  With  the  assistance  of 
Astley  p.  C.  Ashhurst,  M.  D.  Illustrated  with 
more  than  one  hundred  full-page  plates.     Octavo. 

Cloth,  $7.00 

Surgery  of  the  Upper  Abdomen 

Surgical  Diseases  of  the  Stomach;  Duodenum; 
Pancreas;  Liver,  its  Ducts,  Including  Gall- 
stones. Their  Diagnosis,  Technic  of  Opera- 
tions, and  After-Treatment.  Fully  Illustrated. 
Vol.  I. — ^The  Stomach  and  Duodenum.  With 
76  Illustrations,  several  of  which  are  printed  in 
Colors.     Octavo;  xii-l-468  pages. 

Cloth.  $5.00 
Vol.  II. — ^The  Pancreas,  Liver.  Gall-Bladder 
AND  Spleen.  Nearly  Ready. 


^APPENDICITIS...? 


ITS  HISTORY,  ANATOMY,  CLINICAL  .ETIOLOGY,  PATH- 
OLOGY,   SYMPTOMATOLOGY,    DIAGNOSIS, 
PROGNOSIS,     TREATMENT,     TECHNIC 
OF  OPERATION,   COMPLICATIONS 
AND  SEQUELS 


BY 

JOHN  B.  DEAVER,  M.  D.,  Sc.  D.,  LL.  D. 

PROFESSOR   OF   THE   PRACTICE   OF   SURGERY,    UNIVERSITY  OF    PENNSYLVANIA 

SURGEON-IN-CHIEF   TO   THE   GERMAN   HOSPITAL 

VISITING   SURGEON   TO   THE    HOSPITAL   OF   THE   UNIVERSITY   OF   PENNSYLVANIA, 

PHILADELPHIA 


FOURTH  EDITION 
THOROUGHLY  REVISED 


CONTAINING  FOURTEEN  ILLUSTRATIONS 


PHILADELPHIA 

P.   BLAKISTON'S   SON   &  CO, 

1012  WALNUT  STREET 
1913 


I  ^12 


Copyright,  1913,  by  P.  Blakiston's  Son  &  Co. 


THE. MAPLE. PRE SS.YOnK. PA 


TO  THE  MEMORY  OF  MY  FATHER 

J.  M.  DEAVER,  M.  D. 

WHOSE   CHARACTER   AND    STERLING  QUALITIES   AS   A   PHYSICIAN   HAVE 
BEEN    THE    GUIDING    INFLUENCES    OF   MY   PROFESSIONAL    LIFE 

THIS  BOOK  IS  AFFECTIONATELY  DEDICATED 


PREFACE  TO  THE  FOURTH  EDITION 


On  the  appearance  of  the  last  edition  it  seemed  that  the  field  of 
appendicitis  had  been  so  thoroughly  tilled  that  there  was  small 
chance  for  further  growth.  That  such  was  not  the  case  is  best 
evidenced  by  the  fact  that  it  has  been  found  necessary  practically 
to  re- write  sections  of  the  book.  In  doing  this  the  intensely 
practical  nature  of  the  subject  has  been  kept  uppermost  in  mind, 
the  chief  objects  being  to  portray  the  disease  in  its  clinical  aspects 
for  the  benefit  of  student  and  practitioner  whose  opportunities  for 
extensive  special  experience  are  necessarily  Hmited,  and  to  advo- 
cate those  methods  of  treatment  which  the  personal  experience 
and  unabated  interest  of  years  have  led  the  author  to  believe  to  be 
most  salutary.  The  recent  advances  in  the  treatment  of  periton- 
itis in  general,  and  of  appendicular  peritonitis  in  particular,  have 
necessitated  entire  re\dsion  of  that  important  subject  with  expHcit 
formulation  of  our  present  views. 

The  importance  of  chronic  appendicitis  has  increased  during 
the  past  few  years  and  its  various  and  obscure  clinical  manifesta- 
tions have  been  more  clearly  delineated.  The  place  and  meaning 
of  the  leukocyte  count  and  the  differential  formula  have  continued 
to  provoke  discussion  and  are  nearer  solution.  Lane's  bands, 
Jackson's  membrane  and  the  mobile  caecum  have  successively 
been  invoked  to  account  for  symptoms  commonly  ascribed  to 
chronic  appendicitis  which  in  some  cases  are  not  abolished  by  re- 
moval of  the  appendix.  The  extent  to  which  they  are  a  factor  is 
still  a  question  of  interest. 

We  have  wished  to  make  little  change  in  the  chapter  on  Path- 
ology from  the  Master  hand  of  the  late  Dr.  A.  O.  J.  Kelly,  but 
few  additions  or  erasures  having  been  found  necessary.  Increas- 
ing experience  has  made  it  possible  to  add  a  more  adequate  dis- 
cussion of  carcinoma  of  the  appendix. 

I  wish  to  acknowledge  my  obligations  to  Dr.  J.  Bernhard 
Mencke   for  a  large  amount  of   preliminary  work  in   connection 

vii 


viii  Preface  to  the  Fourth  Edition 

with  the  revision;  to  my  clinical  assistant,  Dr.  Damon  B.  Pfeiflfer, 
whose  familiarity  with  my  work  and  methods  has  assisted  greatly 
in  the  satisfactory  exposition  of  the  subject,  and  who, '  with  the 
assistance  of  Dr.  Alexander  Randall,  has  brought  the  chapter 
upon  pathology  up  to  date;  to  Dr.  A.  D.  Whiting  for  helpful  criti- 
cism and  the  preparation  of  the  index:  to  my  resident  physicians 
in  the  German  Hospital  for  help  with  the  records;  finally  to  my 
secretary,  Miss  Patterson:  all  of  whom  have  helped  to  lighten 
the  labors  of  authorship. 


CONTENTS 


Page 

Preface vii 

Table  of  Contents xi 

Description  of  the  Illustrations xii 

History i 

Anatomy 41 

Function  of  the  Cecum  and  Appendix 66 

Clinical  /Etiology 69 

Pathology 80 

The  Lesions  of  the  Appendix 83 

The  Peritonitis  and  Its  Consequences 126 

The   Bacteriology 146 

The  Pathogenesis 154 

Symptomatology 175 

Acute  Appendicitis 176 

Chronic  Appendicitis 189 

Appendicitis  in  Children 196 

Typhoid  Appendicitis 202 

Diagnosis 209 

Differential  Diagnosis 219 

The  Blood  in  Appendicitis 252 

Prognosis 258 

Treatment 264 

Technic  of  Operation 277 

After-treatment 323 

Complications  and  Sequels 335 

Complications  of  Appendicitis 335 

Appendix 355 

Medical  Treatment 355 

List  of  Names 361 

General  Index 367 


IX 


ILLUSTRATIONS 


Fig. 

I 

Fig. 

2 

Fig. 

3 

Fig. 

4 

Fig.     5. 


Fig.     6. 


Fig. 

7- 

Fig. 

8. 

Fig. 

9- 

Fig. 

lO. 

Fig. 

II. 

Fig. 

12. 

Fig. 

13- 

Fig. 

14. 

Page 
From  the  "Anatomy"  of  Andreas  Vesalius,  published  in  1543. 

The  7th  and  8th  figures  from  the  5th  book 3 

Illustration  from  the  work  on  the  "Dissection  of  the  Human 
Body"   by   Stephanus,    published   in    1545,    showing   the 

caecum  and  the  appendix 5 

The  four  primary  types  of  caecum 44 

Positions  of  the  appendix:  under  mesentery;  in  pelvis;  outer 

side  of  caecum 48 

Positions  of   the  appendix:  coiled    up   behind  caecum;  lying 
down  and  out  on  iliac  muscle;  abnormally  long  appendix 

extending  beyond  hepatic  flexure  of  colon 49 

Positions  of  appendix:  on  top  of  mesentery;  on  outer  side  of 
ascending  meso-colon;  and  in  contact  with  external  iliac 

artery 51 

An  unusual  position  of  the  appendix 52 

Vascular  supply  of  right  iliac  fossa 57 

The  ileo-colic  fossa 60 

The  ileo-caecal  fossa 62 

The  sub-caecal  fossa 63 

Myxosarcoma  of  appendix  and  meso-appendix 125 

Intussusception  of  appendix 251 

Skin  incisions  for  appendicitis 281 


XI 


APPENDICITIS, 


HISTORY  OF  APPENDICITIS. 

The  gradual  development  of  any  department  of  science  is  always 
an  interesting  study;  and  this  is  true  to  an  unusual  degree  of  the 
search  for  the  real  cause  of  various  pathological  phenomena  which 
have  been  recognized  from  the  time  of  the  Father  of  Medicine  as 
occurring  in  the  right  iliac  fossa.  So  many  times  does  it  appear 
that  acute  observers  stumbled  on  the  very  threshold  of  the  discovery 
that  the  original  lesion  in  these  conditions  was  in  the  vermiform 
appendix,  that  it  seems  scarcely  credible  that  for  not  much  more  than 
twenty  years  have  we  had  any  adequate  knowledge  of  appendicitis. 

As  in  other  regions  of  the  body,  so  in  the  neighborhood  of  the 
csecum,  a  thorough  appreciation  of  the  anatomy  of  the  parts  con- 
cerned was  required  before  students  of  the  subject  were  prepared 
to  elucidate  the  pathological  conditions  at  times  found  there.  As 
Galen  says,  in  the  quaint  phraseology  of  Peter  Lowe,  "Hard  is  it 
to  cure  any  disease  except  we  first  know  the  nature  and  situation  of 
that  part  whereupon  we  work,  as  also  the  cause  of  the  disease; 
otherwise  neither  salve  is  able  to  prognosticate  of  the  event,  nor 
cure  the  same."  So  it  appears  expedient  to  review  the  rise  of 
knowledge  of  the  anatomy  of  the  appendix  first,  then  to  discuss 
the  clinical  side  of  the  question,  and  finally  to  trace  briefly  the  prog- 
ress of  the  treatment  employed  in  these  cases. 

I 


Appendicitis 


Fig.  I. 

Andrew  Vesalii 

Bruxellensis,  Scholae 

medicorum  Patavina;  professoris,  de 

Humani  corporis  fabrica 

Libri  septem. 

B^ileae,  offici- 

na  Joannis  Oporini, 

Anno  salutis  reparatas  MDXLIII. 

Alense  Junio. 

H,  Ventriculi  portio,  quae  inferius  ventriculi  constituit  orificium,  seu  intestinorum  prin- 
cipium  quod  hie  chordula  ligatum  fiximus. 

I,  K,  Pars  intestinorum  ab  I  ad  K  protenda,  vulgato  nomine  nunc  duodenum  intestinum, 
nunc  intestinum  duodenum  digitorum  longitudine,  mihi  vocatur. 

L,  Jejuni  intestini  initium,  graciliumque  intestinorum  sedes,  ubi  primum  in  anfractus 
convolvi  atque  antrorsum  assurgere  incipiunt. 

M,  Ilei  intestini  terminus,  et  gracilium  intestinorum  finis.  Verum  quanam  sede  jejuni 
intestini  terminus,  aut  ilei  intestini  principium  sit  ponendum,  augurari  nequeo, 
quum  toto  ductu  qui  ab  L  in  septima  figura  in  eadem  et  octava  ad  M  usque  pertinet, 
nullibi  discrimen  commonstret,  quo  jejuni  ab  ileo  liceret  interstinguere. 

N,   Extuberans  crassorum  intestinorum  initium. 

O,  Hoc  intestinum  mihi  caecum  nuncupatur,  non  admodum  contendenti  an  quis  eo 
nomine  aliam  crassorum  intestinorum  partem  donari  velit:  modo  is  non  adeo  nom- 
inum  sit  studiosus,  ut  illorum  occasione  ea  intestinorum  fabrica  negligat,  quae  in 
partium  aliarum  constructione  sedulo  inquirimus. 

N,  P,  Q,  R,  S,  T,  Colum  intestinum  his  characteribus  insignitur,  verum  singuli  privatim 
aliquid  notant.  N  enim  ad  P  usque  coli  intestini  ductum  notat,  a  dextri  renis  sede 
ad  jecoris  usque  cavum  pertinentem.  A  P  vero  ad  Q  coli  ductus  notatur,  secundum 
ventriculi  fundum  a  jecoris  cavo  ad  lienis  usque  regionem  protensus.  A  Q  autem 
ad  R  ductus  coli  insinuatur,  a  lienis  regione  ad  pubis  os,  secundum  sinistrum  ile 
procedens.  Caeterum  ab  R  ad  S  coli  indicatur  ascensus  anfractusque  quem  sursi 
ad  umbilici  usque  regionem  molitur.  At  S  ad  T  usque  progressum  notat.  ducti 
nunc  ascensus  ad  recti  intestini  initium. 

V,  V,  Depressa  coli  intestini  sedes. 

X,  X,  Coli  intestini  utrinque  extuberantes  semiglobuli,  quos  cellulas  vulgus  vocat. 

Y,    Recti  intestini  initium.     Quicquid  vero  sub  Y  consistit,  rectum  est  intestinum. 

Z,    Portio  meatus  bilem  in  intestina  proferentis. 

a,  Musculus  recti  intestini  finem  orbiculatim  amplectus,  faeciumque  excretioni  praefectus. 

b,  c,  Duo  musculi  rectum  intestinum  virorum  peni  et  mulierum  uteri  cervici  interventu 

musculosae  substantiae  connascitur. 


History  of  Appendicitis 


Fig.  I. — I'rom  the  "Anatomy"  of  Andreas  Vesalius,  published  in  1543.     The  7th  and 
8th  figures  from  the  5th  book. 


Appendicitis 


ANATOMICAL  DATA. 

It  has  always  been  a  mooted  question  whether  the  ancients 
— Hippocrates,  Celsus,  Aretaeus,  Galen,  and  others — ever  dissected 
the  human  body.  VesaUus,  writing  in  1543,  impHed  that  Galen 
did  not  describe  an  appendix  to  the  caput  coli  because  he  dissected 
only  monkeys,  which  have  no  appendix;  and  as  Galen,  who  of  all 
the  ancient  writers  gave  by  far  the  most  complete  anatomical 
descriptions,  thus  ignored  so  important  an  organ,  it  is  readily 
understood  that  those  who  immediately  followed  him,  and  even 
the  medical  writers  of  the  middle  ages,  made  no  mention  at  all  of 
the  appendix. 

Not  until  1522  A.D.  is  any  reference  to  this  structure  to  be  found. 
In  that  year  Berengarius  Carpus,  Professor  of  Surgery  at  Pa  via  and 
Bologna,  published  a  work  on  anatomy  in  which  he  spoke  of  there 
being  found  at  the  end  of  the  caecum  a  certain  "additamentum," 
"empty  within,  and  in  breadth  less  than  the  smallest  finger  of  the 
hand,  and  of  a  length  of  three  inches  or  thereabouts."  As  Beren- 
garius is  believed  to  have  been  the  first  modern  who  practised  dis- 
section it  is  probable  that  this  observation  was  original  with  him. 
Vesalius,  writing  twenty-one  years  later,  proposed  that  this  "appen- 
dix" should  properly  be  called  the  caecum,  inasmuch  as  that  part 
generally  termed  caecum  is  not  a  caecum,  or  blind  sac,  but  has  in 
reality  three  openings,  one  each  into  the  ileum,  the  colon  and  the 
appendix.  He  gave  several  illustrations  of  the  abdominal  viscera, 
showing  the  appendix  curled  upon  itself,  both  in  the  body,  and  also 
removed  with  the  whole  bulk  of  the  intestines.  Two  years  after- 
ward, in  1545,  Stephanus  published  at  Paris  his  work  on  the  dis- 
section of  the  human  body.  He  made  no  mention  at  all  of  the 
appendix  in  his  text,  saying  plainly  that  the  caecum  was  called  be- 
cause it  had  no  outlet  at  its  lower  extremity;  however,  he  published 
a  very  curious  plate,  showing  the  appendix  dangling  from  a  very 
capacious  caecum.  He  added  the  information,  quoted  nearly  word 
for  word  from  Galen,  that  in  some  birds  the  caecum  is  double,  "for 
stronger  action." 

Ambroise  Pare  wrote  in  1582  that  "This  intestine  (caecum)  has 
a  long  and  narrow  apophysis,  which  some  have  thought,  evidently 


History  of  Appendicitis 


De  Dissectione  Partium  Corporis  humani  libri  tres,  a  Carolo  Stephano,  doctore 
Medico,  editi.  Una  cum  figuris  et  incisionum  declarationibus,  a  Stephano 
Riverio  Chirurgo  compositis. 

Parisiis 
Apud  Simonem  Colinasum. 

1545- 
Fig.  2. — From  Charles  Estienne's  work  on  the  "Dissection  of  the  Human  Body, 
published  in  1545.     This  illustration  is  from  page  172. 


6  Appendicitis 

erroneously,  slips  down  into  the  scrotum for  it  is  pre- 
vented by  its  close  adherence  to  the  peritoneum."  He  added  that  the 
majority  of  anatomists  of  his  time  understood  by  the  term  caecum 
this  apophysis  which  he  had  just  described. 

Fallopius  wrote  in  his  "Anatomy"  which  was  first  published  in 
1 561,  as  follows:  "After  the  small  intestines  follow  the  large,  the 
beginning  of  which  is  the  caecum,  which  in  man  is  so  small  that  it 
resembles  a  worm  rather  than  an  intestine.  For  it  appears  that 
the  extremity  of  the  colon  ends  off  in  this;  and  that  transversely 
from  where  the  caecum  arises  the  ileum  is  continued,  so  that  the  colon 
appears  to  divide  into  two  branches,  the  shorter  being  the  caecum, 
the  longer  the  ileum.  The  caecum  is  so  called  because  it  has  only 
one  opening.  In  some  animals,  especially  hogs,  monkeys,  dogs, 
and  oxen,  it  is  very  large,  and  seems  to  serve  the  purpose  of  delaying 
the  faeces  for  some  time,  lest  they  should  too  soon  escape  from  the 
body  through  the  large  bowels,  which  is  not  so  apt  to  occur  in  man  on 
account  of  his  erect  posture."  Fallopius  appears  to  have  been  the 
first  writer  to  compare  the  appendix  to  a  worm.  References  to  its 
vermiform  appearance  are  frequent  after  his  time.  Thus  Bauhin 
published  in  1597  an  explanation  of  the  ileo-caecal  valve,  in  which 
he  wrote  of  the  "appendix  lumbricum"  in  a  manner  which  shows 
it  to  have  been  already  well  recognized  in  1579.  He  also  proposed 
the  ingenious  theory  that  the  appendix  served  during  intrauterine 
life  as  a  receptacle  for  the  faeces;  from  which  it  seems  not  improbable 
that  he  confounded  it  with  the  diverticulum  described  nearly  two 
hundred  years  later  by  Meckel,  whose  name  it  bears.  In  his 
anatomical  atlas,  Bauhin  gave  illustrations  calling  the  caput  coli 
the  "caecum  of  Galen,"  and  the  appendix  vermiformis  the  "caecum 
intestinum  posteriorum."  Laurentius,  also,  in  1600  described  the 
appendix  as  a  twisted  worm — "  appendiculam  contorti  lumbrici 
specie." 

Vidus  Vidius  entered  into  more  detail.  He  described  two  coats  to 
the  intestines,  and  said  that  to  these  is  added  a  third  tunic,  from 
the  peritoneum,  which  not  only  adds  firmness,  but  binds  all  the 
intestines  to  the  back  and  vertebral  column.  Joined  to  the  caecum 
he  described  an  appendix,  "not  unlike  a  worm  coiled  in  a  circle." 
He  reproduced  the  illustrations  of  Vesalius.  Tulpius  in  1641  gave 
an  illustration  showing  the  vermiform  appendix,  and  followed  the 


History  of  Appendicitis  7 

teaching  of  Vesalius  in  calling  it  the  "caecum,"  while  he  termed  the 
caput  coli  the  "colon." 

Fabricius  ab  Aquapendente  likewise  described  the  human  caecum 
as  very  small,  as  if  it  were  an  appendix,  oblong  and  very  narrow, 
rivahng  a  worm  in  appearance;  at  autopsy,  he  added,  he  had  at  times 
found  a  worm  in  it.  This  appendix,  which  he  called  caecum,  he  said 
was  bound  by  folds  of  membrane  to  the  sides  of  the  ilium  (sic),  and 
its  chief  function  {loc.  cit.,  f.  147)  he  thought  to  be  to  hold  the  caput 
coli  in  place,  as  a  ligament.  He  discussed  in  some  detail  the  caecum 
of  animals,  of  birds  and  of  fishes,  and  recognized  from  comparative 
anatomy  that  man's  appendix  takes  the  place  of  the  lower  end  of 
the  caecum,  which  in  man  is  not  nearly  so  capacious  as  in  the  lower 
animals  that  have  no  appendix. 

Morgagni,  in  his  "Adversaria  Anatomia,"  first  published  in 
1706,  devoted  condiserable  space  to  an  account  of  the  vermiform 
appendix.  He  said  that  hitherto  it  had  been  considered  to  exercise 
one  of  two  functions,  either  to  receive  something  from,  or  to  give 
something  to,  the  intestinal  tract.  The  former  function  Morgagni 
believed  to  be  impossible  because  of  the  size  of  the  appendix  and 
the  condition  of  its  lumen  and  its  orifice.  As  an  instance  in  sup- 
port of  his  views,  he  quoted  the  observation  of  Zambeccarius,  who, 
although  he  cut  off  a  portion  of  the  appendix  of  a  puppy-dog, 
ligating  it,  yet  after  three  months  found  the  base  of  the  appendix 
clearly  open,  and  yet  no  faecal  matter  had  fallen  from  it  into  the 
abdominal  cavity.  Morgagni  asserted  that  the  appendix  does  not 
hang  down  from  the  caecum,  but,  as  it  were,  empties  itself  down  into 
the  caecum.  Of  ten  cadavers  which  he  examined  in  only  two  did 
the  appendix  open  into  the  middle  of  the  base  of  the  caecum;  in  the 
eight  others  the  orifice  was  to  the  left,  between  the  base  of  the  caecum 
and  the  ileo-caecal  valve.  In  two  other  cases  he  observed  that  the 
appendix  even  pointed  perpendicularly  upward,  one  being  without 
any  curvature  closely  applied  to  the  caecum.  He  gave  good  illus- 
trations of  the  caecum  and  appendix. 

Verheyen  gave  "appendix  vermiformis"  as  .a  marginal  heading 
in  his  work  on  anatomy  published  in  17 10.  He  said  there  was  much 
dispute  as  to  the  application  of  the  word  caecum,  whether  it  should 
be  used  with  reference  to  the  caput  coli,  as  was  done  by  the  ancients, 
or  to  the  appendix,  as  we  have  seen  was  first  done  in  1543  by  Vesalius. 


8  Appendicitis 

Verheyen  sided  with  the  ancient  authors,  in  favor  of  calhng  the  caput 
coli  the  caecum. 

Santorini  in  1724  wrote  of  having  seen  the  appendix  lying 
directly  upward  between  the  psoas  muscle  and  the  hollow  of  the 
liver.  At  autopsies  he  had  also  observed  faecal  concretions  and 
worms  in  the  appendix,  and  had  in  one  instance  found  the  appendix 
absent.  He  noted  the  appearance  of  a  meso- appendix,  and  thought 
the  chief  function  of  the  appendix  was  to  serve  as  a  nest  for  round 
worms,  where  they  might  be  cherished,  and  be  prevented  from 
escaping  into  the  general  intestinal  tract. 

Lieberkiihn's  essay,  which  appeared  in  1739,  is  looked  upon 
as  a  classic  in  this  department  of  literature.  He  remarked  that  he 
could  understand  readily  from  its  construction  that  some  have 
asserted,  while  others  have  denied,  that  faecal  matter,  when  the 
appendix  is  wounded,  escaped  into  the  abdomen.  Referring  to 
the  experience  of  Zambeccari,  as  reported  by  Morgagni,  he  said, 
"This  I  have  also  observed  myself,  but  of  several  dogs  not  even  one 
lived  till  the  next  day  after  the  operation." 

Vosse  in  1749  appears  to  have  been  the  first  to  recognize  the 
part  played  by  the  various  pockets  of  the  peritoneum  around  the 
caecum  in  concealing  the  appendix  from  view.  He  said  that  some- 
times the  appendix  hides  beneath  the  caecum,  and  hence  is  not  found. 
He  also  observed  some  cases  in  which  the  caecal  orifice  of  the  appen- 
dix was  the  narrowest  part  of  its  lumen,  and  in  three  out  of  six 
cadavers  he  noted  that  the  orifice  was  occluded  by  a  fold  of  mucous 
membrane.  Weitbrecht,  who  died  in  1747,  also  said  he  observed 
a  valve  at  the  caecal  orifice  of  the  appendix.  Haller  in  1778  stated 
that  in  the  foetus  the  appendix  is  relatively  larger  than  in  the  adult — 
often  half  the  size  of  the  ileum. 

Sabatier  in  1781  called  attention  to  the  large  number  of  mucous 
glands  in  the  appendix,  but  added  nothing  new  to  the  knowledge 
of  its  anatomy. 

Since  the  close  of  the  eighteenth  century  the  gross  anatomy  of 
the  appendix  has  been  fairly  well  known:  its  three  coats;  its  mucous 
glands,  and  their  abundant  secretion;  the  meso-appendix,  and  the 
folds  produced  by  the  peritoneum  in  this  region — these  were  dis- 
cussed in  more  or  less  detail  by  all  anatomical  writers  during 
the   early   part   of    the   nineteenth   century.     In   the   succeeding 


History  of  Appendicitis  9 

decades,  among  an  innumerable  number  of  articles  on  this  phase  of 
the  subject,  a  few  stand  out  as  of  preeminent  importance.  Gerlach 
in  1847  called  renewed  attention  to  the  fold  of  mucous  membrane 
which  may  act  as  a  valve  in  occluding  the  orifice  of  the  appendix, 
and  which  has  since  gone  by  his  name;  and  in  1859  he  still  further 
discussed  the  anatomy  of  this  organ. 

Treitz  in  1857  described  the  peri-caecal  fossae,  but  no  adequate 
account  of  these  folds  of  peritoneum  appeared  until  1891,  when 
Lockwood  and  RoUeston  published  their  elaborate  studies,  while 
Clado,  in  the  next  year,  in  an  exhaustive  article,  aroused  interest  in 
a  fold  of  peritoneum  running  from  the  ovary  to  the  meso-appendix, 
and  since  known  under  his  name,  as  Clado's  ligament. 

The  minute  anatomy  of  the  appendix  has  not  received  attention 
until  comparatively  recent  years,  some  of  the  best  studies  being 
those  of  Lockwood. 

CLINICAL  DATA. 

"Suppuration  upon  a  protracted  pain  of  the  parts  about  the 
bowels  is  bad."  This  aphorism  of  Hippocrates  forms  practically 
the  first  recorded  observation  of  a  disease  known  for  centuries 
subsequently  under  the  rather  vague  name  of  the  iliac  or  the  colic 
passion.  Its  cause  was  not  understood,  but  it  was  explained,  in  a 
manner  more  or  less  satisfactory  to  themselves,  by  the  various 
authors  of  classic  times.  Another  aphorism  of  Hippocrates  records 
the  fact  that  from  the  rupture  of  an  internal  abscess  prostration  of 
strength,  vomiting,  and  deUquium  animi  result.  That  some  of  these 
cases  seen  by  the  Father  of  Medicine  were  instances  of  appendicular 
abscess  is  scarcely  for  a  moment  to  be  doubted.  That  many  of 
them  were  other  affections  seems  even  more  certain. 

Celsus,  who  lived  in  the  latter  part  of  the  first  century  B.C., 
and  in  the  early  part  of  the  first  century  of  our  era,  distinguished 
between  the  colic  passion,  situated  in  the  large  intestines  (and 
therefore,  according  to  him,  below  the  umbilicus),  and  the  iliac 
passion,  an  affection  afflicting  the  small  bowel  exclusively,  and  there- 
fore having  its  seat  entirely  above  the  navel  These  two  terms, 
iliac  and  colic  passion,  were  used  by  medical  writers  until  well  toward 
the  end  of  the  eighteenth  century,  without  there  being  made  any  very 


lo  Appendicitis 

great  distinction  between  the  two,  either  as  regards  causation, 
symptoms  or  treatment;  and  what  at  one  period  were  considered 
rather  indicative  of  the  colic  passion  were  symptoms  at  another  time 
attributed  to  the  other.  Celsus  made  the  chnical  observation  that 
the  cohc  passion  was  more  often  on  the  right  of  the  abdomen,  near 
the  caecum,  than  on  the  left;  and  he  also  noted  that  it  was  very  apt 
to  recur.  Aretaeus,  who  is  believed  to  have  lived  about  one  hundred 
years  later,  considered  death  from  the  pain  alone,  in  cases  of  the 
iliac  passion,  quite  possible,  even  before  local  lesions  had  formed; 
while,  he  added,  some  survive  the  pain  only  to  die  of  suppuration  or 
gangrene  of  the  bowels. 

Galen,  writing  in  the  close  of  the  second  century  a.d.,  said  the 
iliac  passion  was  an  inflammation  of  the  intestines,  so  that  neither 
flatus  nor  faecal  matters  can  pass  through;  "violent  gripes  follow, 
and  intolerable  pains."  Oribasius,  a  medical  writer  of  the  fourth 
century,  although  his  complete  works  were  not  published  until 
1858,  asserted  that  ileus  was  due  only  to  inflammations,  and  that  the 
lumen  of  the  bowels  may  or  may  not  be  obstructed,  according  to 
the  seat  of  the  lesion  and  its  severity.  If  the  inflammation  arises 
high  in  the  intestinal  tract,  obstruction  is  not  complete,  but  if  the 
large  bowel  is  affected  the  obstruction  is  complete.  He  recognized 
the  formation  of  peritoneal  abscesses,  but  added  nothing  new. 

None  of  these  writers  paid  much  attention  to  differential  diag- 
nosis, although  they  recognized  that  symptoms  such  as  these  might 
be  caused  by  volvulus,  intussusception,  strangulated  hernia,  and 
other  pathological  conditions. 

The  Arabian  school  of  medicine,  which  forms  the  bridge  between 
the  classic  and  the  mediaeval,  is  fairly  represented  by  Avicenna,  who 
flourished  in  the  eleventh  century.  He  made  the  usual  distinction 
between  the  colic  and  iliac  passions,  but  contented  himself  with  saying 
that  the  causes  of  both  were  the  same,  although  the  symptoms  of  the 
iliac  were  more  severe,  and  required  more  strenuous  treatment.  He 
considered  it  a  good  sign  if  the  pain  shift,  a  bad  sign  if  it  remain  in 
one  place,  or  if  an  abscess  form.  The  occurrence  of  this  last  com- 
plication might  be  suspected  if  the  pain,  having  become  fixed  in 
one  place,  became  of  a  throbbing  character,  with  a  feeling  of  weight, 
pulsation,  and  inflammation,  with  acute  fever,  redness  and  swelling. 

Among  the  earliest  of  the  mediaeval  writers  is  Arnaldus  Vil- 


History  of  Appendicitis  ii 

lanovanus,  who  flourished  about  1300  a.d.  He  added  to  the  stereo- 
typed description  of  this  disease  the  opinion  that  one  form  of  passion 
may  turn  into  the  other,  or  that  both  may  exist  at  once.  If  the 
disease  persists  and  becomes  severe  abscesses  may  form. 

FerneHus  recorded  in  1567  a  case  of  ileus,  or  iHac  passion, 
from  obstructed  and  narrowed  "caecum,"  in  a  girl  nine  years  of  age. 
This  child  had  been  suffering  from  a  diarrhoea,  and  her  grand- 
mother, taking  counsel  "with  other  old  women,"  decided  to  give  her 
a  quince,  this  fruit  being  known  from  the  time  of  Dioscorides  for  its 
extreme  astringency  in  the  green  state.  As  a  consequence  of  this 
dose  the  diarrhoea  was  not  only  checked,  but  no  passage  from  the 
bowels  occurred  at  all  that  day  and  the  following  night:  the  most 
excruciating  and  agonizing  pains  arose  in  the  abdomen,  which 
swelled  up  in  a  marvelous  manner.  A  physician  being  now  called 
in,  and  suspecting  what  the  trouble  was,  endeavored,  but  in  vain,  to 
alleviate  the  child's  sufferings,  first  by  mild,  and  then  by  more  active 
enemata,  and  by  soothing  abdominal  applications.  Finally  the 
vomiting  became  stercoraceous  in  character,  there  were  frequent 
periods  of  deliquium  animi,  and  within  two  days  a  pitiable  death 
ended  the  child's  pain.  At  the  autopsy  the  "caecum"  was  found  to 
have  the  interior  of  its  "duct"  narrowed  and  constricted  by  the  re- 
mains of  the  quince,  with  the  result  that  the  "corrupt  matter," 
being  prohibited  from  its  normal  outlet  ("meatus"),  had  made  an 
unaccustomed  way  for  itself,  by  perforating  the  intestine  above  the 
obstruction,  and  thus  had  filled  the  whole  abdominal  cavity.  It  is 
an  interesting  question  whether  Fernelius  understood  by  the  term 
"caecum"  the  vermiform  appendix,  as  did  his  contemporaries 
Vesalius  and  Fallopius,  and  as  did  even  some  fifty  years  later  Tulpius. 
It  is  to  be  recollected  that  Pare  said  that  most  of  the  anatomists  of 
his  time  understood  the  word  caecum  as  referring  to  the  vermiform 
appendix.  That  this  was  the  case  with  Fernelius  seems  probable 
when  we  consider  the  application  of  the  words  "  duct"  and  "  meatus," 
which  do  not  seem  particularly  appropriate  to  the  caput  coli. 
Moreover,  the  scholia,  by  Simon  Paulus,  which  follow  this  case 
where  it  is  quoted  in  the  "  Sepulchretum "  of  Bonetus,  are  largely 
concerned  with  the  function  of  the  "caecum  intestinum,"  which  is 
referred  to  as  "that  apophysis,"  a  little  appendix  ("appendicula"), 
sewed  on  to  the  junction  of  the  small  and  large  intestine,  and  is 


12  Appendicitis 

further  described  as  having  been  taken  from  the  bodies  of  still  living 
dogs  by  the  writer's  son,  John  Henry  Paul,  who  found  that  this 
"appendicula"  was  generally  filled  with  faecal  matter,  and  often 
had  in  its  lumen  "little  drops  of  its  own  kind  of  excrement,  as  yet 
unnamed  by  anatomists." 

Reading  then  "appendix  vermiformis"  for  "caecum"  in  the 
above  reported  case,  we  evidently  have  an  instance  of  appendicitis, 
which  is  the  earliest  thus  far  known.  But  even  if  we  consider  it  as 
a  case  of  appendicitis,  it  is  evident  from  subsequent  writers  that  the 
vermiform  appendix  was  not  for  a  long  time  afterward  recognized 
as  a  cause  of  disease.  Yet  the  works  of  Erastus,  who  published  his 
commentary  on  Paracelsus  in  1572,  show  a  distinct  advance  in 
dififerential  diagnosis.  Paracelsus  had  taught  that  all  colic  pains 
came  from  flatus,  whereas  Erastus  himself  said  very  distinctly  that 
some  of  these  cases  were  due  to  inflammations,  and  that  the  variety  so 
arising  was  more  difficult  to  cure  as  well  as  of  less  frequent  occurrence. 
The  colic  pains  arising  from  inflammation  became  fixed  to  one  place, 
and  by  this  fact,  together  with  the  presence  of  bilious  vomiting,  thirst, 
fever  and  wakefulness,  the  more  serious  disease  might  be  distinguished 
from  that  due  only  to  wind. 

In  1612  Peter  Lowe  treated  briefly  of  the  iliac  passion,  and  gave 
the  interesting  information,  on  the  authority  of  Lonicerius,  that 
"Hippocrates  did  die  of  this  disease."  Lowe  did  not  even  mention 
the  appendix  in  this  connection.  Fabricius  ab  Aquapendente 
(1634)  described  both  the  colic  and  the  iliac  passion,  the  causes  and 
signs  of  both  being  the  same  in  kind,  but  those  of  the  iliac  much 
worse  in  degree.  His  account  is  in  every  way  inferior  to  that  of  his 
contemporary  Fabricius  Hildanus,  who  often  made  autopsies  in 
those  who  had  died  of  the  iliac  passion,  and  always  found  lesions 
around  the  ileo-caecal  region.  He  thought,  however,  that  the  affec- 
tion originated  as  an  inflammation  of  the  ileo-caecal  valve,  which 
thus  caused  intestinal  obstruction  by  swelling  and  occluding  the 
lumen  of  the  bowels.  Most  of  these  cadavers,  he  ingenuously  added, 
smelt  so  horribly  that  he  was  not  very  minute  in  his  examination. 

Saracenus  in  1642,  in  a  letter  to  a  medical  friend,  gave  the 
details  of  a  case  occurring  in  a  woman  of  fifty  years,  which  he  thought 
sufficiently  curious  to  be  thus  recorded.  There  arose  in  her  right 
groin  a  swelling,  which  at  length  suppurated,  and  finally  pointed  and 


History  of  Appendicitis  13 

broke  externally,  discharging  for  a  long  time  pus  of  a  filthy  odor. 
As  gangrene  of  the  parts  seemed  imminent,  the  physician  in  charge 
of  the  case  applied  an  escharotic  ointment.  Soon  after  this  the 
sinus  began  to  discharge  half-digested  food  and  faecal  matters  from 
day  to  day;  so  that  it  was  easy  to  recognize  in  the  discharge  whatever 
the  patient  had  eaten  shortly  before,  especially  such  matters  as 
dried  plums.  After  awhile  six  lumbricoid  worms  were  discharged. 
From  all  these  symptoms  Saracenus  concluded  that  a  lesion  of  the 
large  intestines  was  indisputable.  It  was  not  until  she  had  reached 
this  stage  of  the  disease  that  Saracenus  saw  her  himself,  but  with  his 
own  eyes  he  beheld  eight  worms  discharged  from  the  faecal  fistula 
at  various  times.  By  degrees  the  ulcer  contracted,  the  faecal  dis- 
charge became  less,  and  the  patient  returned  to  good  health,  although 
Saracenus  expressed  the  anticipation  that  a  return  of  her  trouble 
was  to  be  apprehended.  He  told  his  friend  that  he  would  advise  him 
of  the  further  progress  of  the  case;  also  that  he  was  under  the  impres- 
sion that  he  had  seen  a  similar  case  described  somewhere,  but  could 
not  recall  the  author's  name.  Unfortunately  Roussel,  who  first  pub- 
lished this  letter,  fails  to  inform  us  where  he  discovered  the  original 
epistle  of  Saracenus,  nor  does  he  say  whether  Saracenus  fulfilled 
his  promise  of  recording  the  patient's  subsequent  history.  However 
this  may  be,  there  can  be  little  doubt  in  any  one's  mind  that  this  is 
the  earliest  known  example  of  recovery  from  a  peri-appendicular 
abscess. 

Helmont  said  (1664)  that  all  abdominal  pains  were  from  flatus, 
and  that  all  obstructions  may  be  removed  by  swallowing  lead  bullets. 
He  did  not  mention  the  appendix,  nor  did  he  speak  of  inflamma- 
tion as  a  cause  of  the  iliac  passion.  Two  years  later,  in  1666, 
Sydenham  made  the  important  clinical  observation  that  in  the  com- 
mencement of  this  disease  the  pain  is  less  fixed  than  it  becomes  later, 
when  it  is  wont  to  settle  to  one  spot,  and  remain  there.  It  is  true 
that  Avicenna  recognized  the  fact  that  the  pain  at  times — ^when  an 
abscess  forms — becomes  fixed  to  one  spot;  but  it  seems  that  Syden- 
ham was  the  first  to  lay  stress  on  this  localization  of  the  symptoms  as 
one  of  the  most  valuable  diagnostic  points;  in  fact,  he  seems  to  have 
had  an  inkling  that  these  symptoms  arose  from  a  disease  that  was 
distinct  in  its  causation  from  volvulus,  strangulated  hernia,  intus- 
susception, and  all  other  intra-abdominal  affections.     Erastus,  to  be 


14  Appendicitis 

sure,  nearly  a  hundred  years  before  Sydenham,  had  noted  that  the 
pain  became  fixed  in  all  inflammatory  diseases  of  the  abdomen,  but 
he  does  not  appear  to  have  been  aware,  as  Sydenham  apparently 
was,  that  there  was  one  disease  especially  characterized  first  by 
diffuse  abdominal  pain,  and  then  by  pain  settling  to  the  part  of  the 
abdomen  affected,  which  disease  was  later  proved  to  be  appendicitis. 
As  causes  of  this  disease,  Sydenham  gave  improper  indulgence  in  the 
fruits  of  the  season,  or  in  any  indigestible  food.  He  remarked  that 
the  disease  was  prone  to  return  after  recovery. 

In  1682  Thomas  Willis  wrote,  "Inflammation  or  sphacelus 
about  the  beginning  of  the  colon,  which  I  have  often  noted,  arises 
from  vain  efforts  to  expel  faecal  matters,  which  becoming  stagnated 
against  the  ileum,  produce  the  ihac  passion."  Baglivus  (1696) 
added  his  testimony  to  the  usual  symptoms  of  this  malady,  by  stating 
that  when  a  colic  pain  becomes  fixed,  and  a  fever  supervenes,  it  is 
accustomed  to  terminate  in  abscess;  not  so  if  the  pain  shifts  from 
place  to  place. 

Boerhave,  who  first  published  his  "Aphorisms"  in  1709,  gra- 
phically described  the  course  of  events  in  this  disease  somewhat  as 
follows:  Inflammation  of  the  bowels  produces  an  obstruction,  which 
causes  an  ardent  fixed  pain;  vomiting  ensues,  and  an  iliac  passion 
is  formed,  whence  an  abscess  or  gangrene  may  arise;  then  follows  "  a 
most  sharp  fever,  and  extreme  weakness,  from  the  violent  pains, 
which  next  close  by  a  speedy  death."  He  added  a  caution  to  the 
attending  physician  which  is  not  without  its  value  at  the  present  day: 
"As  long  as  this  malady  continues  in  its  inflammatory  stage,  it  often 
imposes  upon  those  who  are  incautious  under  the  name  of  a  colicky 
pain,  by  whom  it  is,  with  the  most  dangerous  events,  ascribed  to  cold, 
to  wind,  or  to  flatulencies,  and  accordingly  ill-treated  by  carminative 
and  hot  medicines,  with  the  most  fatal  consequences."  If  he  be  not 
cured,  either  an  abscess  will  form,  and  rupture  into  the  bowels,  with 
recovery,  or  into  the  abdominal  cavity,  with  death;  or  else  gangrene 
will  occur,  and  a  quiet  death  speedily  ensue. 

Santorini  in  1724  wrote  of  having  observed  faecal  concretions 
as  well  as  worms  in  the  appendix  at  autopsies. 

Ruyschius,  his  contemporary,  tried  to  differentiate  the  various 
causes  of   the   iliac  passion,  but  did  not  mention  the  appendix. 

In  1735  Amyand  operated  on  an  inguinal  hernia  in  which  he 


History  of  Appendicitis  1 5 

found  the  perforated  vermiform  process.  This  case  will  be  more 
fully  discussed  under  the  head  of  Treatment. 

CrelHus  in  1752  published  notes  of  an  autopsy,  in  which  he  de- 
scribed a  peculiar  vermiform  appendix  which  he  found  in  a  woman. 
This  appendix  was  not  only  larger  and  more  capacious  than  is 
usual  in  adults,  but  was  filled  with  a  compact  substance.  On 
opening  the  caput  coli  he  found  the  cascal  orifice  of  the  appendix 
unusually  large,  admitting  with  ease  the  tip  of  the  little  finger,  and 
its  lumen  filled  with  fsecal  matter  in  the  form  of  little  globules.  This 
phenomenon  he  thought  supported  the  theory  of  those  who  maintain 
that  the  function  of  the  appendix  was  to  serve  during  intra-uterine 
life  as  a  receptacle  for  the  faeces,  inasmuch  as  in  the  present  case  he 
found  on  further  search  that  the  descending  colon  was  constricted 
to  the  size  of  the  small  bowel,  while  the  ascending  and  transverse 
portions  of  the  colon  were  remarkably  dilated. 

Heister  in  1753  published  the  details  of  a  case  in  which  he  had 
made  an  autopsy  as  early  as  17 11.  In  the  abdomen  of  a  mal- 
efactor he  found  the  vermiform  process  gangrenous  and  lying  in 
a  small  collection  of  pus,  among  adhesions.  This  proves,  said 
Heister,  that  this  part  can  be  the  seat  of  inflammation  and  abscess  as 
well  as  other  parts;  a  fact  which  he  thought  had  not  been  sufficiently 
noted  before.  And  if  we  reject  the  case  of  Fernelius,  cited  above, 
this  case  of  Heister's  is  undoubtedly  the  first  instance  known  in 
which  the  lesions  are  positively  stated  to  be  in  the  appendix. 
For  the  case  recorded  by  Saracenus  is  merely  one  of  faecal  fistula 
following  suppuration  in  the  right  iUac  region,  the  patient  not 
coming  to  autopsy,  so  far  as  we  know,  and  the  appendix  not  being 
mentioned  in  any  way. 

In  1755  Wedels  recorded  a  recurrent  attack  of  iliac  passion  which 
had  been  observed  in  1670.  The  patient  experienced  sudden, 
causeless  pain  in  the  right  iliac  region,  similar  in  character  to  that 
occurring  one  year  before;  there  was  fever  and  vomiting,  with  local 
tenderness,  and  a  mass  was  palpable.  The  affection  was  rebellious 
to  clysters,  but  the  patient  recovered  on  the  third  day,  after  a  dose 
of  opium.  In  the  same  year  Garmanns  saw  a  woman  who  had  an 
abscess  over  the  region  of  the  caecum  which  was  opened  by  poultices, 
and  discharged  many  round  worms.     This  patient  also  recovered. 

In  1759,  four  years  after  the  publication  of  these  cases,  Mestivier 


1 6  Appendicitis 

reported  a  fatal  case  of  abscess  on  the  right  side  of  the  umbiUcus, 
found  at  the  postmortem  examination  to  be  due  to  the  perforation 
of  the  appendix  by  a  pin. 

In  1766  de  Lamotte  found,  at  an  autopsy  on  a  man  who  died 
after  acute  abdominal  pains,  intestinal  obstruction  and  peritonitis, 
that  the  appendix  was  much  enlarged,  and  contained  a  large  con- 
cretion the  size  of  an  orange,  but  resembling  a  potato  in  appearance, 
though  more  spherical.  This  concretion  weighed  four  ounces. 
Although  there  was  no  perforation  he  recognized  the  appendix 
as  the  cause  of  the  disease. 

In  1768  Herlin  discussed  the  function  of  the  appendix,  stating 
that  in  1734  M.  Delatoison  made  an  autopsy  on  a  man-servant 
who  had  died  of  the  iliac  passion,  and  who  had  been  made  to  swallow 
three  large  balls  (in  hope  of  overcoming  the  obstruction).  These 
were  found  in  the  appendix,  which  was  dilated  by  faecal  matters 
nearly  to  the  size  of  the  rest  of  the  gut. 

In  1778  Haller  wrote  that  he  had  twice  seen  the  lumen  of  the 
appendix  obliterated;  and  that,  wonderful  as  it  may  seem,  it  had 
been  possible  to  remove  the  appendix  without  harm  not  alone  from 
hens,  but  even  from  man  and  dogs.  "Mirum  videri  possit,  potuisse 
non  gallinis  solis,  sed  homini  (hernioso  Zambeccari  apud  Fantonum) 
sed  canibus  ipsis,  absque  noxa  absecari."  The  reference  to  the 
ruptured  patient  of  Zambeccarius,  as  quoted  by  Fantonus,  it  has 
been  impossible  to  find. 

In  1794  Baillie  in  describing  the  pathological  anatomy  of  the 
vermiform  process  said  that  he  had  seen  it  varying  from  as  long  as 
five  inches  to  scarcely  a  half  inch  long;  that  he  had  noted  its  presence 
in  a  congenital  hernia,  lying  close  to  the  testicle;  had  seen  its  canal 
obliterated;  and  had  found  both  worms  and  earthy  concretions  in  it. 

In  1808  Jadelot  observed  the  case  of  a  boy,  which  clinically 
showed  only  fever  of  an  adynamic  type.  At  the  autopsy  lumbricoid 
worms  were  found  in  the  ileum,  caecum,  and  appendix. 

In  181 2  Parkinson  saw  a  young  man  who  was  ill  for  two  days 
with  abdominal  symptoms.  At  the  autopsy  he  found  the  distal 
one  inch  only  of  the  appendix  swollen  and  inflamed,  and  perforated. 
Nearer  the  base  of  the  organ  was  a  faecal  concretion  impacted  in 
the  lumen.  The  caecum  and  other  viscera  were  normal  except  for 
the  peritonitis.     Copeland  was  more  fortunate  in  a  case  which  he 


History  of  Appendicitis  '  1 7 

observed  the  same  year :  a  fascal  abscess  developing  in  the  right  groin 
was  opened  by  poultices;  some  weeks  later  an  oval  calculus,  a  half 
inch  long,  was  removed  from  the  sinus  with  forceps.  The  faecal 
discharge  lessened,  and  complete  cure  resulted. 

In  1813  Wegeler  recorded  the  case  of  a  youth  of  eighteen,  who, 
after  a  fit  of  anger,  drank  a  quantity  of  ice-water.  Soon  he  exper- 
ienced excruciating  abdominal  pains  in  the  right  iliac  region,  well 
localized.  Persistent  bilious  vomiting  developed,  which  after  twelve 
hours  became  stercoraceous.  Wegeler  diagnosed  "  that  well  known 
obscure  form  of  enteritis,  later  turning  into  ileus,  as  an  effect, 
not  a  cause."  At  autopsy  the  caecum  was  found  destroyed  by  gan- 
grene, which  evidently  had  arisen  from  the  base  of  the  appendix. 
This  process  itself,  of  an  even  more  intensely  red  color  was  larger 
than  usual,  and  its  mesentery  injected.  It  contained  many  calculi. 
Wegeler  was  very  far,  he  said,  from  thinking  these  calculi  were  the 
origin  of  the  disease;  but  he  could  very  readily  be  led  to  believe  that 
an  inflammation  arising  elsewhere  would  rather  attack  a  part  so 
affected  than  some  other  region,  and  thus  the  severity  of  the  disease 
be  markedly  increased. 

In  181 5  is  found  what  is  apparently  the  first  American  case  to 
have  been  reported.  Prescott  narrated  that  his  patient  had  had  pain 
in  the  right  iliac  region  for  about  one  year,  when  he  was  suddenly 
attacked  with  a  very  severe  pain  in  this  region,  and  died  on  the  fifth 
day,  after  symptoms  of  general  peritonitis  had  developed.  The 
autopsy  showed  the  caecum  with  the  neighboring  parts  of  the  colon 
and  ileum  sphacelated,  and  the  caecal  orifice  of  the  appendicula 
vermiformis  obstructed  by  a  cocoa  or  chocolate  nut,  which  was 
recognized  as  the  cause  of  the  disease.  Prescott  says  that  he  is 
not  familiar  with  any  similar  case,  but  suggests  foreign  bodies  in 
the  appendix  as  a  cause  for  many  symptoms  arising  in  the  right 
iliac  region. 

In  1824  Louyer-Willermay  recorded  two  fatal  cases  of  peritoni- 
tis due  directly  to  perforation  of  the  appendix;  and  Blackadder  a 
case  in  which  death  occurred  about  three  hours  after  the  onset  of 
acute  abdominal  symptoms,  with  a  semi-comatose  condition  of  the 
patient.  The  autopsy  in  Blackadder's  case  disclosed  as  the  only 
abdominal  lesion  the  vermiform  appendix  immensely  distended  by 
a  huge  lumbricoid  worm,  but  with  no  perforation.     The  heart  was 


i8  Appendicitis 

the  seat  of  long  standing  disease.  Blackadder  said  he  had  also 
observed  faecal  concretions  in  the  appendix,  and  called  attention  to 
this  fact  in  connection  with  the  operation  recently  proposed  by 
Monro  for  the  purpose  of  removing  such  concretions  from  the  caecum 
by  the  extra-peritoneal  route.  No  one,  however,  appears  to  have 
followed  this  suggestion  until  1883,  when  Symonds,  at  the  instance 
of  Mahomed,  successfully  extracted  a  calculus  from  the  appendix, 
in  the  manner  described  by  Blackadder. 

In  1827  Husson  and  Dance  at  the  suggestion  of  Dupuytren, 
who  later  published  his  own  views,  discussed  diseases  of  the  caecum 
at  considerable  length.  They  held  that  as  a  rule  the  retro-peritoneal 
cellular  tissue  was  first  involved  in  these  cases,  but  that  in  rare 
instances  the  peritoneum  itself  was  first  inflamed,  the  disease  attack- 
ing the  cellular  tissue  only  at  a  later  date.  If  the  abscess  formed 
were  intra-peritoneal,  and  this  they  thought  was  always  the  case 
unless  the  cellular  tissue  were  first  attacked,  then  its  rupture  into 
the  bowels  was  very  rare,  these  cases  usually  terminating  by  general 
peritonitis  and  death.  Some  cases  they  had  observed  as  long  as 
nine  and  even  sixteen  years  ago,  the  patients  having  recovered  after 
rupture  of  the  abscess  into  the  bowels,  and  having  had  no  return 
of  symptoms  since. 

Melier  in  this  year  made  a  further  advance  in  describing  diseases 
of  the  appendix  with  considerable  accuracy,  believing  them  to  be 
entirely  distinct  from  caecal  trouble.  He  even  went  so  far  as  to  say: 
"If  it  were  possible  to  establish  with  certainty  the  diagnosis  of  this 
affection,  we  could  see  the  possibility  of  curing  the  patient  by  opera- 
tion. We  will,  perhaps,  some  day  arrive  at  this  result."  This 
brilliant  article  of  Melier's  appears  to  have  fallen  upon  barren 
ground.  Most  of  his  contemporaries  do  not  even  mention  it.  Yet 
it  is  by  all  means  the  most  important  contribution  to  the  literature 
of  appendicitis  prior  to  the  well-known  article  by  Fitz,  in  1886. 
For  lucidity  of  opinion,  and  near  approach  to  modern  teaching  it  is 
probably  unexcelled. 

In  1827  also  Wickham  reported  a  fatal  case  of  perforated 
appendix  in  a  boy,  two  calculi  being  found  in  the  appendix. 

In  1828  Meniere  collected  thirteen  cases  of  acute  phlegmonous 
tumors  in  the  right  iliac  fossa,  and  reviewed  three  such  cases  already 
reported  by  Husson  and  Dance.     He  considered  all  such  cases  to 


History  of  Appendicitis  19 

be  due  to  retro-caecal  cellulitis.  He  reported  also  chronic  cases  {loc. 
cit.,  p.  532),  saying  that  in  one  case  he  had  observed  the  appendix 
acquire  a  circumference  of  more  than  four  inches,  thus  making  one 
believe  in  the  existence  of  cancer  of  the  caecum.  Ponceau,  he  said, 
reported  three  examples  of  these  affections  of  the  right  iliac  fossa. 

It  is  interesting  to  note  that  Jobert,  in  a  work  devoted  exclu- 
sively to  the  surgical  affections  of  the  intestinal  canal,  published  in 
1829,  did  not  even  mention  the  appendix  in  his  description  of  the 
anatomy  of  the  parts,  nor  did  he  refer  to  any  lesions  to  which  it 
might  give  rise. 

In  1830  Goldbeck,  at  the  suggestion  of  Puchelt  of  Heidelberg, 
chose  this  disease  as  the  subject  of  his  graduation  thesis.  Following 
the  recent  French  writers,  he  considered  two  distinct  affections, 
one  involving  the  appendix,  and  the  other,  perityphlitis,  as  quite 
distinct;  he  stated  that  in  fatal  cases  of  this  latter  affection  the  appen- 
dix had  been  found  intact.  Bodey,  in  his  Paris  thesis  of  this  same 
year,  noted  that  he  had  seen  five  cases  of  perforation  of  the  appendix, 
in  all  of  which  general  peritonitis  was  for  a  time  prevented  by  the 
formation  of  adhesions,  which  finally  being  broken  through,  allowed 
death  from  faecal  extravasation.  He  gave  the  details  of  two 
cases. 

In  1 83 1  Waldron  reported  a  fatal  case  of  perforated  appendix, 
with  a  concretion;  and  Ferrall  published  a  monograph,  in  which  he 
adhered  to  the  view  that  in  phlegmonous  tumors  of  the  right  iliac 
fossa  the  caecum  is  the  organ  primarily  involved,  and  that  the  retro- 
caecal  connective  tissue  is  a  more  important  factor  in  the  subsequent 
course  of  the  case  than  is  either  the  appendix  or  the  peritoneum. 
Tumors  in  the  right  iliac  fossa  he  thought  might  be  classified 
advantageously  under  three  heads:  (i)  Faecal  impaction,  without 
inflammation.  (2)  Malignant  tumor  of  the  caecum.  (3)  True 
phlegmonous  or  inflammatory  masses,  proceeding  from  irritation 
of  the  mucous  membrane  of  the  caecum,  or  from  ulceration  and  per- 
foration of  its  wall. 

In  1832  Iliff  reported  three  fatal  cases  as  follows:  in  the  first, 
death  occurred  from  a  general  purulent  peritonitis,  caused  by  a 
foreign  body  which  had  ulcerated,  but  not  perforated  the  vermiform 
process;  in  the  second,  a  bean  was  found  in  the  appendix  at  autopsy; 
while  in  the  third,  although  the  pain  during  life  was  chiefly  on  the 


20  Appendicitis 

left  side  of  the  abdomen,  yet  the  postmortem  examination  showed 
a  calculus  lodged  in  the  appendix. 

In  1833  Dupuytren  published  the  views  which  he  had  been 
teaching  for  some  years.  He  asserted  that  these  abscesses  in  the  right 
iliac  region  were  developed  around  the  csecum  outside  of  the  perito- 
neum, but  were  capable  of  causing  inflammation  in  this  membrane. 
As  the  most  trustworthy  symptoms  he  recognized  pain,  resistance, 
tension,  with  a  palpable  mass  developing  after  a  time,  and  tenderness. 
He  thought  that  abscesses  opening  through  the  abdominal  wall  were 
nearly  always  fatal,  because  drainage  was  so  difficult.  Of  sixteen 
cases  of  abscess,  with  which  he  was  familiar,  only  one  died.  He 
did  not  mention  the  appendix  in  this  article,  but  in  the  second  edition 
of  his  "Lemons  Orales,"  published  in  1839,  he  reported  a  case  of 
perforation  of  the  appendix  already  recorded  by  Meniere,  in  which 
the  caecum  and  the  surrounding  parts  had  "returned"  to  their  normal 
state,  while  the  appendix,  nearly  disorganized,  communicated  with 
an  abscess  cavity  between  the  anterior  abdominal  wall  and  the 
parietal  peritoneum.  Dupuytren  added  that  inflammations  and 
diseases  of  the  appendix,  of  which  he  had  seen  a  fairly  large  number, 
had  not  fixed  the  attention  of  authors,  but  that  Melier  had  written 
an  excellent  article  on  this  subject.  Although  Dupuytren  reported 
several  similar  cases,  in  none  other  did  he  recognize  the  appendix 
as  the  true  seat  of  the  disease;  and  it  is  probably  in  large  measure 
due  to  his  teachings  that  an  appreciation  of  the  real  state  of  affairs 
slumbered,  in  the  minds  of  a  few  observers  only,  for  the  next  fifty 
years. 

In  1834  Boyer  noted  a  death  following  perforation  of  the  ileo- 
caecal  valve.  Petrequin  considered  this  absurd,  and  called  it  a  case 
of  perforated  appendix.  The  original  report  obscures  the  true  con- 
dition by  inaccuracy  of  expression  and  typographical  errors. 

In  1834  Copland  entered  upon  a  study  of  the  diseases  of  the 
caecum  in  greater  detail,  and  pointed  out  that  inflammation  of  the 
appendix  might  give  rise  to  very  serious  affections  in  the  caecal 
region.  He  further  mentioned  "mortification"  of  the  appendix 
from  the  lodgment  of  a  foreign  body,  and  said  that  this  might  be 
followed  by  fatal  peritonitis,  but  did  not  consider  inflammation  of 
the  appendix  ever  a  cause  of  localized  suppuration. 

In  the  year  1835  the  most  important  contribution  to  the  subject 


History  of  Appendicitis  21 

was  a  further  article  from  the  pen  of  Louyer-Willermay,  who 
referred  again  to  his  earHer  cases  (1824),  and  insisted  on  the  appendix 
as  the  cause  of  the  disease.  He  claimed  for  himself  the  priority  iii 
noting  this  fact.  Ahrt  in  the  same  year  reported  a  case  in  Berlin,  in 
which  he  had  opened  an  abscess  over  the  caecum,  which  he  thought 
the  cause  of  the  disease.  He  did  not  mention  the  appendix. 
Pierou  also  reported  cases :  the  first  fatal  from  perforation  of  the  ap- 
pendix; and  the  second  in  a  patient  who  suffered  from  symptoms  of 
intestinal  obstruction  in  the  right  iliac  region,  ending  in  recovery, 
after  an  abscess  had  pointed  in  the  right  ischiatic  region.  This 
latter  case  he  diagnosed  as  one  of  appendiceal  perforation. 

In  1836  von  Merling  pubhshed  an  extremely  important  mono- 
graph on  the  pathological  anatomy  of  the  vermiform  process. 
He  gives  a  very  complete  review  of  the  cases  of  diseased  appendices 
hitherto  reported,  and  discusses  their  lesions  under  the  following 
heads:  (i)  Absence  of  the  appendix.  (2)  Obliteration  of  its  canal. 
(3)  Length  and  size.  (4)  Displacements.  (5)  Adhesions.  (6) 
Foreign  bodies.  (7)  Inflammation  without  foreign  bodies.  (8) 
Ulcerations.  In  discussing  the  influence  of  foreign  bodies  he 
recognized  two  classes  of  cases:  first,  those  in  which  no  symptoms 
were  present  during  life,  the  offending  substances  being  found  only 
postmortem;  and  second,  those  in  which  the  foreign  body  evidently 
caused  death  by  the  inflammation  which  it  produced.  Under  the 
seventh  heading  he  recorded  two  cases  now  reported  for  the  first  time: 
the  first,  observed  by  Tiedemann,  consisted  in  cystic  degeneration 
of  the  appendix,  the  csecal  opening  having  become  obliterated;  the 
second,  observed  by  Hoffacker,  was  in  the  person  of  a  young  student, 
in  whom,  after  death  from  abdominal  disease,  the  autopsy  showed 
inflammation  starting  in  the  caecum  and  colon,  and  extending  to  the 
appendix,  which  was  mostly  destroyed.  Hoffacker's  opinion  was, 
says  Merling,  that  an  abscess  had  first  arisen,  and  had  subsequently 
destroyed  the  caecum  and  appendix.  Another  case  here  reported  was 
that  of  an  appendix  found  at  autopsy  adherent  to  the  large  bowel  on 
the  left  of  the  abdomen,  a  probe  passing  from  the  caecum,  through 
the  appendix,  into  the  large  intestine.  The  only  instances  of  ulcera- 
tion of  the  appendix  without  perforation  noticed  by  Merling  were 
two  previously  reported,  where  the  affection  was  recognized  as 
tuberculous. 


22  Appendicitis 

Another  important  paper  on  diseases  of  the  caecum  and  vermi- 
form appendix  appeared  in  1837  in  England.  This  was  by  Burne, 
who  maintained  the  still  prevailing  view  that  most  affections  in  the 
right  iliac  fossa,  of  which  he  had  seen  some  twenty  examples,  were 
due  to  primary  involvement  of  the  caecum.  He  reported  eight  cases, 
in  only  three  of  which  did  he  think  the  appendix  at  fault.  The 
cause,  he  added,  was  not  idiopathic,  in  any  such  cases,  but  generally 
due  to  the  lodgment  in  the  caecum  of  indigestible  food.  The  most 
reliable  symptoms,  he  held,  were  pain  and  exquisite  tenderness. 
About  the  fifth  or  sixth  day  the  ''turn"  of  the  case  occurred,  where- 
upon either  recovery  ensued,  or  an  abscess  formed.  In  the  appendix 
cases  he  called  attention  to  the  importance  of  the  position  of  the  ap- 
pendix in  determining  the  position  of  the  abscess.  Slight  ulcerations 
of  the  appendix  from  foreign  bodies  were  often  found,  he  said,  and 
caused  no  particular  inconvenience;  but  if  the  foreign  body  should 
become  impacted,  gangrene  from  pressure,  followed  by  perforation, 
would  ensue.  In  accord  with  the  views  of  those  days  in  regard  to 
the  pathology  of  inflammation,  he  asserted  that  even  with  ulceration 
no  inflammation  arises  until  the  peritoneum  is  involved,  when  an 
abscess  will  result  from  local  inflammation,  or  general  peritonitis  if 
the  inflammation  spreads.  Two  years  later  Burne  wrote  a  second 
paper,  in  which  he  maintained  that  the  caecum  was  of  comparatively 
little  importance  in  affections  of  the  right  iliac  region.  He  thought 
that  practically  all  cases  of  caecal  inflammation  recover,  and  that  where 
perforation  took  place  in  the  caecum  it  was  always  to  be  attributed 
to  the  existence  of  disease  previous  to  the  acute  attack  which  appears 
to  be  the  cause  of  death.  Thus  if  perforation  of  the  caecum  occurred 
from  within  he  held  that  it  was  due  to  tubercular  or  other  ulcera- 
tion; whereas  if  it  occurred  from  the  outer  surface  it  would  be 
caused  by  disease  of  the  adjacent  vermiform  appendix.  He 
reported  several  new  cases,  the  most  interesting  being  one  of  "sero- 
enteritis  arising  in  the  peritoneal  tunic  of  the  appendix,"  in  which 
the  lumen  of  the  appendix  was  pervious,  and  the  mucous  membrane 
not  diseased,  but  the  coats  were  much  thickened,  and  local  peritonitis 
was  present,  with  serous  exudation  and  many  adhesions.  His  con- 
clusions were  that  of  affections  in  the  right  iliac  fossa  those  of  the 
caecum  were  most  frequent  and  least  serious ;  that  perforation  of  the 
appendix  held  second  place;    perforation  of    the  caecum  coming 


History  of  Appendicitis  23 

third;  while  very  rare  indeed  was  inflammation  of  the  appendix 
without  perforation. 

While  there  was  nothing  particularly  new  in  these  papers  of 
Burne,  they  mark  one  more  authority  ranking  himself  on  the  side 
which  was  constantly  gaining  recruits,  that  which  recognized  the 
existence  of  two  distinct  diseases  in  the  right  iliac  region,  the  more 
serious  of  which  had  the  vermiform  process  as  its  cause. 

In  1837,  also,  cases  of  perforated  appendix  were  reported  by  Von 
Pommer  Esche  and  by  Corbin,  the  latter's  patient  being  a  phthisical 
man,  and  the  lesion  of  the  appendix  probably  tuberculous.  Both 
patients  died.  Petrequin,  in  this  year  contributed  an  article  in 
which  he  noted  the  function  of  the  omentum  in  covering  in  the  appen- 
dix and  localizing  abscesses. 

In  1838  Albers  noted  the  possibility  of  the  occurrence  of  disease 
in  the  right  iliac  fossa  as  the  result  of  inflammation  of  the  vermiform 
process,  but  thought  that  it  more  often  arose  in  the  Ccecum.  Under 
the    name    of    "typhlitis"    he    described   four   distinct   affections: 

1.  Stercoral    typhlitis — irritation    from    faecal    matter. 

2.  Simple   typhlitis — catarrhal  inflammation  from   any  cause. 

3.  Perityphlitis — extension  of  the  disease  from  the  mucous  lining 
of  the  bowel  to  its  serous  coat  and  the  surrounding  tissues. 

4.  Chronic  typhlitis — in  which  the  course  of  the  disease  was  slow 
and  prolonged. 

When  pus  formed  and  a  perforated  appendix  was  found,  he 
considered  that  the  perforation  was  due  to  the  previous  formation  of 
pus. 

In  1838  another  tuberculous  perforation  of  the  appendix  was 
recorded  by  Hallowell,  producing  death  in  about  twelve  hours 
from  suppurative  peritonitis.  Hornung  also  reported  a  fatal  case  of 
perforated  appendix. 

Grisolle,  in  1839  collected  in  all  seventy-three  cases  of  phlegmon 
in  the  right  iliac  fossa,  and  recognizes  perforation  of  the  caecum  or 
its  appendix  as  an  occasional  cause  of  this  affection. 

From  this  date  on  the  reported  cases  of  perforation  or  other 
disease  of  the  vermiform  process  become  so  numerous,  that  mere 
mention  of  all  would  be  impracticable  in  a  work  of  this  kind;  there- 
fore all  that  will  be  attempted  will  be  a  reference  to  the  more  im- 


24  ^  Appendicitis 

portant  articles,  with  passing  comment  on  any  advances  that 
appear  to  have  been  made  in  the  pathology  or  diagnosis  of  such 
affections. 

Rokitansky  is  remembered  for  having  first  called  marked  atten- 
tion to  catarrhal  inflammations  of  the  appendix.  In  his  "Hand- 
book of  Pathological  Anatomy,"  published  at  Vienna  from  1841  to 
1846,  he  described  diseases  of  the  vermiform  appendix  in  the  fol- 
lowing words:  "Catarrhal  inflammation  of  the  vermicular  process 
is  a  disease  of  common  occurrence,  and  very  dangerous  on  account 
of  its  consequences.  It  much  resembles  typhlitis  stercoralis,  and 
is  invariably  the  result  of  faecal  matters  and  foreign  bodies,  especially 
small  fruit  stones,  having  become  lodged  and  hardened  in  it.  The 
affection  has  a  torpid  character,  may  exist  for  a  long  time  as  blenor- 
rhoea,  and  is  accompanied  by  thickening  of  the  coat  of  the  vermi- 
cular process.  After  frequent  exacerbations  it  passes  into  ulceration, 
which  may,  if  the  foreign  body  remains  loose,  attack  the  entire 
process,  or  if  the  former  becomes  fixed,  affect  only  the  point  of 

attachment,    or    the    end    of    the    vermicular    process 

Under  favorable  circumstances the  vermicular  process 

shrivels  up  and  forms  a ligamentous  ap- 
pendix.    In  the    opposite  case  the  ulceration brings  on 

perforation This is   not  immediately  followed 

by  general   peritonitis,    inasmuch   as   the   previous   irritation  has 

induced  adhesions The   adhesions  gradually  give  way, 

and  general  peritonitis  ensues."  Rokitansky  had  observed  also 
cystic  degeneration  of  the  appendix,  as  well  as  typhoid  and 
tuberculous   ulcers   causing  perforation. 

Another  good  article  on  the  diagnosis  and  pathology  of  diseases 
of  the  appendix  is  the  editorial  in  the  Archives  Generales  de  Mede- 
cine,  for  1841,  in  which  are  included  reports  of  cases  by  Malespine 
and  by  Briquet;  the  editors  reviewed  also  the  articles  of  Burne, 
Petrequin,  Merling,  Grisolle,  and  others,  and  apparently  recognized 
the  fojlowing  forms  of  disease: 

1.  Peri-appendicular  non-suppurative  inflammation,  which  may 
resolve  without  pus-formation. 

2.  Peri-appendicular  abscesses,  which  may  terminate  by  rup- 
ture either  into  the  bowels  or  intra-peritoneally ;  or  may  be  opened 
externally. 


History  of  Appendicitis  25 

3.  General  peritonitis  from  perforation  of  the  appendix,  without 
any  attempt  at  localization  of  the  process. 

As  astiological  factors  they  recognized:  (i)  Foreign  bodies  and 
faecal  concretions.  (2)  Tuberculous  or  other  ulcerations.  (3) 
Some 'undefined  causes  producing  inflammation  without  perforation. 

In  1843  ^  0I2  published  an  essay  in  which  he  upheld  the  rather 
unpopular  view  that  the  appendix  was  responsible  for  more  of  the 
affections  of  the  right  iliac  fossa  than  was  the  caecum.  He  reported 
five  cases,  and  in  the  first  four  the  diagnosis  was  confirmed  by 
autopsy,  but  although  his  fifth  patient  recovered  he  was  sure  the 
lesion  had  been  a  perforation  of  the  appendix.  The  symptoms 
on  which  he  placed  most  reliance  were  abdominal  pain,  which  soon 
became  localized  to  the  region  affected,  and  local  tenderness.  He 
thought  there  was  not  apt  to  be  any  fever,  and  that  the  pulse  rate 
usually  was  not  accelerated.  In  this  stage  of  the  disease  recovery 
might  occur,  or  on  the  other  hand  general  peritonitis  might  super- 
vene, with  diffused  pain  and  tenderness,  tympanites,  intestinal 
obstruction,  small  fast  pulse,  cold  extremities  and  death. 

In  1846  Ormerod,  although  he  described  several  cases  of  right 
iliac  abscesses,  yet  made  no  mention  whatever  of  the  appendix; 
which  shows  that  even  at  this  comparatively  late  date  the  cause  of 
the  appendix  was  far  from  being  won. 

In  1847  Walther  said  that  the  catarrhal  form  of  the  disease  was 
more  severe  than  that  due  to  foreign  bodies,  although  he  thought 
that  perforation  was  only  possible  when  these  were  present.  He 
expressed  the  belief  that  concretions  form  in  the  oecum,  and  ulti- 
mately press  aside  the  valve  of  the  appendix,  and  enter  its  lumen. 
Cless  in  1847  diagnosed  a  perforation  of  the  appendix,  which  was  con- 
firmed by  the  autopsy. 

Oppolzer,  in  1858,  made  a  further  advance  in  the  pathology 
of  inflammations  of  the  appendix,  when  he  divided  iliac  phlegmons 
into:  (i)  Extra-peritoneal,  and  (2)  Intra-peritoneal.  He  thought 
that  inflammation  of  the  appendix  must  produce  the  latter  variety. 

In  1859  Leudet  abandoned  the  idea  that  inflammation  of  the 
right  iliac  region  arose  in  the  caecum,  and  contended  that  perforation       yr 
of  the  appendix  was  more  common  than  perforation  of  all  other 
parts  of  the  intestine  combined;  and  noted  that  such  perforation  may 
open  into  the  caecum,  rectum,  vagina  or  bladder,  or  through  the 


26  Appendicitis 

abdominal  wall.  He  also  considered  some  cases  of  abscess  of  the 
liver  and  pylephlebitis  as  dependent  upon  this  disease.  He  con- 
sidered localized  suppuration  a  more  common  result  of  perforation 
of  the  appendix  than  general  peritonitis. 

In  1867  Dr.  Wm.  Pepper  noted  the  cure  of  an  old  lesion  of  the 
appendix  by  conversion  of  the  organ  into  a  fibrous  cord. 

In  1875  Wilks  and  Moxon  stated  that  the  appendix  usually  was 
at  fault  in  these  troubles,  but  still  considered  that  inflammation  ot 
the  caecum,  with  perforation  producing  abscess  and  peritonitis,  did 
sometimes  occur,  although  they  expressed  the  opinion  that  in  severe 
cases  the  appendix  was  the  seat  of  disease.  They  moreover  recog- 
nized the  fact  that  perforation  was  not  always  necessary  to  produce 
suppurative  peritonitis. 

In  1880  Bierhoff  gave  a  very  complete  account  of  the  pathology 
of  the  appendix,  though  he  made  no  marked  advance  from  the 
teachings  of  Merling,  in  1836.  As  causes  he  gave,  besides  foreign 
bodies  or  concretions,  and  a  catarrh  which  forms  part  of  a  general 
intestinal  inflammation:  (i)  Other  acute  diseases,  as  typhoid  fever, 
dysentery,  cholera,  etc.;  (2)  neoplasms,  as  tuberculosis  and  carcin- 
oma; and  (3)  parasites,  of  which  the  Ascaris  lumbricoides  is  the 
most  frequent.  A  more  important  contribution  in  this  same  year  is 
that  of  Matterstock  who  showed  that  of  146  autopsies  in  adults 
with  peri-caecal  suppurations,  in  no  less  than  132  was  the  appendix 
perforated,  while  among  49  autopsies  in  children  with  perityphlitis, 
this  organ  was  found  perforated  in  37  cases.  But  With,  of  Copen- 
hagen, was  probably  the  first  to  deny  outright  that  typhlitis  could 
ever  itself  give  rise  to  peritonitis.  He  called  the  disease  "perit- 
onitis appendicularis,"  and  recognized  three  forms :  (i)  Peritonitis 
appendicularis  universalis.  (2)  Peritonitis  appendicularis  localis. 
(3)  Peritonitis  appendicularis  adhaesiva. 

In  1885  Fox  first  proposed  the  theory  that  perityphlitis  was 
strictly  analogous  to  quinsy,  an  inflammation  in  the  peritonsillar 
tissues,  being  led  to  this  idea  from  a  consideration  of  the  resemblance 
in  structure  of  the  appendix  and  the  tonsil,  both  being  very  rich  in 
lymphoid  tissue;  and  also  because  he  recognized  the  fact  that  in 
less  than  half  the  cases  of  inflammation  of  the  appendix  could 
foreign  bodies  be  held  accountable. 

Reginald  H.  Fitz,  beginning  in  1886,  in  a  memorable  article 


History  of  Appendicitis      "  2  7 

published  in  the  American  Journal  of  the  Medical  Sciences,  gave  an 
impetus  to  the  study  of  affections  of  the  vermiform  appendix  such 
as  it  had  never  before  received,  and  by  showing  that  the  symptoms 
in  209  cases  of  typhlitis  or  perityphlitis  were  identical  with  those 
observed  in  257  cases  of  perforation  of  the  appendix,  convinced  the 
medical  world  of  the  practical  truth  of  the  contention  that  in  all 
inflammations  of  the  right  iliac  fossa  the  "fons  et  origo  mali"  was 
the  vermiform  process  of  the  csecum.  It  seems  that  in  this  article 
the  term  "appendicitis"  is  first  used;  and  though  many  physicians 
objected  to  it  as  "a  rather  barbarous  word,"  or  as  "an  excessively 
clumsy  term,"  yet  its  convenience  was  recognized  by  all,  and  it  soon 
displaced  all  competitors,  such  as  "apophysitis,"  "ecphyaditis," 
"epityphhtis,"  and  "scolecoiditis."  Whatever  may  be  said  in 
favor  of  these  various  terms,  the  last  of  which  has  greatest  claims 
to  consideration  on  philological  grounds  (o-kwA-j^,  lumbricus,  a 
worm),  the  word  appendicitis,  so  widely  in  use  in  America,  England, 
France,  and  wherever  the  languages  of  these  countries  are  spoken, 
cannot  be  dropped,  even  were  it  desirable  to  do  so. 

For  a  number  of  years  after  the  publication  of  these  articles  by 
Fitz,  there  were  still  a  few  isolated  physicians  who  maintained  that 
there  were  two  distinct  diseases  met  with  in  the  right  iliac  region, 
typhlitis  and  appendicitis ;  but  few  if  any  asserted  that  the  latter  was 
the  less  frequent  of  the  two. 

The  greatest  of  all  advances  in  the  diagnosis  of  appendicitis 
was  that  accomplished  by  McBurney  when  he  described  a  point  one 
and  a  half  to  two  inches  from  the  anterior  superior  iliac  spine  on  a 
line  drawn  thence  to  the  umbilicus,  as  the  spot  where  localized  pain 
and  tenderness  were  almost  invariably  found  in  cases  of  inflammation 
of  the  appendix,  this  being  the  usual  situation  of  the  base  of  that 
organ.  It  was  a  valuable  advance  not  so  much  because  the  pain 
is  in  every  case  just  at  that  spot,  but  because  it  put  into  the  physi- 
cian's or  the  surgeon's  thoughts,  in  a  practical,  concrete  way,  a 
ready  method  of  excluding  nearly  every  other  disease  with  almost 
absolute  certainty;  and  though  it  is  not  possible  to  deny  the  existence 
of  appendicitis  when  pain  and  tenderness  are  in  another  place,  it  is 
a  very  rare  thing  for  the  signs  to  be  circumscribed  in  this  way  and 
for  the  affection  to  be  other  than  appendicitis. 

The  bacteriology  of  the  appendix  next  claimed  the  attention 


28  Appendicitis 

of  writers  and  we  find  among  the  first  to  make  such  reports  of  their 
cases  GouiUioud  and  Adenot  in  1891. 

In  1894  Senn  pubHshed  an  article  on  "Appendicitis  ObHt- 
erans,"  but  for  next  ten  to  fifteen  years  the  chief  subject  of  discus- 
sion was  the  treatment,  the  pathology  and  diagnosis  having 
become  more  or  less  firmly  established.  This  was  so  because 
operations  constantly  were  being  undertaken  at  an  earlier  date. 
By  this  means  it  has  been  shown  that  foreign  bodies  play  a  compara- 
tively insignificant  role  in  the  causation  of  appendicitis,  that  per- 
foration is  by  no  means  the  only  way  in  which  peritonitis  can  arise, 
and  that  an  appendix  once  the  seat  of  inflammation  never  returns  to 
its  normal  state,  even  if  the  patient  can  avoid  a  recurrence  of  the 
symptoms  by  careful  diet  and  regularity  of  life. 

TREATMENT. 

To  describe  in  any  detail  the  various  remedies  recommended 
by  the  ancients  for  colic  pains  and  ileus,  would  be  neither  suitable 
in  a  sketch  such  as  this,  nor  particularly  edifying.  Sufiice  it  to  say 
that  any  surgical  treatment  was  postponed  until  the  last  possible 
moment,  when  an  abscess  was  actually  pointing;  and  even  in  such  a 
case  the  vast  majority  preferred  to  let  the  matter  evacuate  itself 
spontaneously,  or  to  allow  the  patient  to  die  a  peaceful  death  without 
subjecting  him  to  the  discomfort  of  the  abscess  being  opened  at  all, 
and  without  laying  themselves  open  to  the  charge  of  having  killed 
the  patient  by  the  operation.  Yet  that  abdominal  abscesses  were 
occasionally  incised,  is  proved  by  the  instance  cited  by  Aretaeus  in 
the  second  century.  He  opened  an  abscess  "in  the  colon  on  the 
right  side,  near  the  liver,  and  much  pus  rushed  out,  and  much  also 
passed  by  the  kidneys  and  bladder  for  several  days,  and  the  man 
recovered."  It  would  be  too  much  to  assume  that  he  was  treating 
a  case  of  appendicitis,  which  had  ulcerated  into  the  urinary  tract, 
yet  the  possibility  of  this,  among  other  greater  probabilities,  is  not 
to  be  denied. 

In  the  earlier  stages  of  the  disease,  the  course  of  treatment  was 
somewhat  as  follows :  Immediate  venesegtion  from  the  veins  at  the 
elbow,  and,  if  retention  of  urine  was  present,  from  the  saphenous 
vein  at  the  ankle  as  well;  blood  being  drawn  in  severe  cases  ad 


History  of  Appendicitis  29 

deliquium  animi.  Emetics  if  the  pain  were  above  the  navel;  purga- 
tives, however,  should  its  chief  intensity  be  below;  but  in  cases  where 
there  was  manifest  inflammation,  these  remedies  were  not  used, 
evacuation  of  the  bowels  being  attempted  by  large  and  repeated 
enemata,  forcefully  injected.  Sedatives  were  given  sparingly, 
because  it  was  thought  that  obstruction  of  the  bowels  was  best 
overcome  by  purgatives,  although  they  were  administered  only  by 
enema,  as  above  stated,  in  cases  of  inflammatory  obstruction,  the 
patient  under  such  circumstances  rejecting  every  medicine  from  the 
stomach  by  the  prolonged  vomiting.  While  sedatives  were  thus  not 
given  by  mouth,  they  were  directed  to  be  applied  locally;  and  the 
patient  was  made  to  sit  in  a  bath  of  hot  oil  in  which  various  drugs 
were  dissolved.  A  very  few  of  the  ancient  physicians  caused  their 
patients  to  swallow  leaden  pills,  in  the  hope  that  by  their  weight 
they  might  force  a  way  through  all  obstructions,  and  finally  cause  a 
satisfactory  faecal  evacuation. 

Later— in  the  time  of  Oribasius — it  was  customary  to  encourage 
the  opening  of  an  abscess  into  the  bowels  by  hardening  the  over- 
lying skin  with  astringents;  and  warm  and  emollient  cataplasms 
were  applied  only  when  rupture  externally  appeared  unavoidable. 
These  same  methods  of  treatment  were  pursued  by  the  Arabian 
physicians  with  little  change  and  practically  no  improvements. 

In  the  time  of  Pare  (sixteenth  century),  abscesses  were  opened 
without  hesitation  when  they  pointed  externally;  and  great  reliance 
was  placed  in  the  virtues  of  quicksilver  to  overcome  intestinal 
obstruction.  Thus  Zacutus  Lusitanicus  informs  us  that  Marianus 
Sanctus  narrated  that  many  were  cured  of  the  most  deplorable  iliac 
passions  by  drinking  three  pounds  of  quicksilver  in  hot  water, 
"which  even  saved  them  from  imminent  death."  It  is  curious  to 
find  this  remedy  still  in  use  at  as  late  a  date  as  1830.  Pedrini, 
moreover,  in  1883,  reported  three  cases  of  "ileus"  successfully 
treated  by  causing  the  patients  to  swallow  five  or  six  bullets  and  four 
pounds  of  No.  3  shot,  at  the  same  time  using  prolonged  and  repeated 
insufflation  of  air  by  the  rectum. 

Van  Helmont,  in  1664,  boldly  pronounced  that  no  one  can  perish 
of  the  iliac  passion  if  he  do  but  swallow  musket  balls  of  lead,  which 
by  their  superincumbent  weight  may  drive  forward  the  obstacle 
seated  in  the  intestines;  and  that  the  larger  these  balls  were,  and 


30  Appendicitis 

the  greater  the  number  of  them  swallowed,  the  more  expeditiously 
would  they  be  useful,  especially  if  the  patient  could  be  kept  upon  his 
feet  and  walking  about  in  an  erect  posture. 

Sydenham's  favorite  application  to  the  abdomen  in  these  cases 
was  the  body  of  a  freshly  slain  puppy-dog,  slit  open.  In  those 
cases  where  the  pain  returned  after  recovery,  or  where  symptoms  of 
abdominal  discomfort  persisted  after  an  attack  of  the  iliac  passion, 
he  recommended  constant  horseback  riding,  to  jolt  the  noxious 
matters  out  of  the  caecum,  where  they  were  prone  to  accumulate. 

Riverius  in  1668  narrated  the  following  incredible  case,  quoted 
from  Matthew  de  Gradi :  A  girl  of  twelve  years  was  afflicted  with  the 
iliac  passion,  and  reversed  peristalsis  became  so  strong,  and  faecal 
vomiting  so  constant,  that  not  only  were  ordinary  suppositories 
vomited  from  the  mouth  shortly  after  being  placed  in  the  rectum,  but 
even  one  tied  by  four  strong  threads  to  the  thigh  was  drawn  upward, 
the  strings  snapped,  and  the  suppository,  with  parts  of  the  threads 
still  attached,  shortly  afterward  rejected  from  the  stomach.  Besides 
giving  the  usual  directions  as  to  treatment  Riverius  laid  great  stress 
on  abstinence,  allowing  only  three  spoonfuls  of  broth  every  day,  for 
four  or  five  days. 

Boerhaave,  the  most  learned  of  all  medical  writers,  in  1709 
advised  the  following  treatment  for  cases  such  as  these: 

1.  Large  and  repeated  bloodlettings. 

2.  Laxative  and  cooling  clysters,  three,  four,  or  more  in  a  day. 

3.  Similar  drinks,  with  a  "prudent  interposition  of  opiates." 

4.  Fomentations  to  the  abdomen,  more  especially  of  living 
animals  that  are  young  and  of  sound  health,  split  open  and  applied. 

5.  Avoiding  all  things  that  are  acrid,  forcing  or  heating. 

6.  Holding  on  in  the  same  course  until  complete  cure  is  assured, 
that  is,  until  all  symptoms  have  been  absent  for  three  days. 

In  1735  is  found  the  first  authentic  reference  to  the  removal  of 
the  human  appendix  during  life.  Claudius  Amyand,  Esa,.,  F.  R.  S., 
operated  on  a  boy,  eleven  years  of  age,  for  the  cure  of  a  discharging 
sinus  in  the  right  thigh,  which  evidently  communicated  with  an 
irreducible  scrotal  hernia.  The  hernia  had  existed  from  infancy, 
and  for  one  month  there  had  been  discharged  from  this  fistula 
"a  great  quantity  of  an  unkindly  matter."  As  it  was  evident  that 
the  cure  of  the  sinus  depended  upon  that  of  the  hernia,  "which 


History  of  Appendicitis  31 

latter  could  be  obtained  by  no  other  operation  than  that  for  the 
bubonocele,"  this  was  agreed  to,  and  the  operation  accordingly 
performed  on  the  sixth  day  of  December,  1735.  "This  operation 
proved  the  most  complicated  and  perplexing  Mr.  A.  ever  met  with, 
many  unsuspected  oddities  and  events  concurring  to  make  it  as 
intricate  as  it  proved  laborious  and  difficult."  The  hernia  was 
found  to  be  chiefly  omental,  "the  size  of  a  small  pippin,"  and  in  its 
interior  lay  the  appendix  casci,  which  had  been  perforated  by  the 
point  of  a  pin,  whose  head,  covered  with  much  incrusted  stone, 
remained  within  the  appendix,  acting  as  a  ball  valve,  and  allowing 
at  most  unexpected  and  inopportune  moments  a  copious  discharge 
of  faecal  matter  over  the  field  of  operation.  The  long  standing  in- 
flammation had  so  knit  together  the  sac  of  the  hernia,  the  omentum, 
the  appendix,  and  the  testicle  and  cord,  that  their  dissection  was  a 
most  intricate  and  perplexing  procedure.  Besides  all  these  adhe- 
sions, there  was  the  additional  difficulty  of  the  sudden  and  over- 
whelming discharge  of  faeces,  frequently  occurring;  the  facts  that  the 
pin  was  continually  getting  in  the  way  of  the  knife,  that  the  exact 
whereabouts  and  form  of  the  gut  could  not  be  detected,  and  that 
Mr.  Amyand  could  not  be  sure  how  it  ought  to  be  treated  until  he 
could  see  it.  However,  the  omentum  was  first  dissected  loose,  cut  off 
close  to  the  abdominal  muscles,  and  the  stump  allowed  to  retract  into 
the  adominal  cavity  without  any  ligatures,  as  there  did  not  appear 
to  be  any  good-sized  vessels  in  it.  Having  completed  this  tedious 
dissection,  the  gut  was  next  found,  loosened  from  its  adhesions,  and 
the  aperture  from  which  faeces  had  all  this  while  been  escaping,  at 
last  detected.  As  the  pin  was  withdrawn  from  the  appendix  a 
report  was  heard  like  that  when  a  cork  is  drawn  out  of  a  bottle,  so 
tightly  did  its  enlarged  head  fit  the  lumen  of  the  appendix.  The 
bowel  was  now  plainly  seen  to  be  the  appendix  caeci,  and  the  con- 
sensus of  opinion  of  the  physicians  and  surgeons  present  was  that  it 
would  be  proper  to  amputate  this  gut.  "To  which  end  a  circular 
ligature  was  made  about  the  sound  part  of  it,  two  inches  above  the 
aperture;  and  this,  being  cut  off  an  inch  below  the  ligature,  was 
replaced  in  the  abdomen,  in  such  a  manner  than  an  artificial  anus 
might  be  made  there,  if  the  patient's  case  should  require  it."  Then 
the  hernial  sac  was  cut  off,  as  high  up  as  it  had  been  possible  to 
dissect  it  from  the  skin,  spermatics,  etc.;  and  these,  as  they  appeared 


32  Appendicitis 

in  a  sound  state,  were  preserved  in  situ.  The  fistulous  tract  was 
pared,  and  its  edges  freshened,  "the  aperture  in  the  (abdominal) 
muscles,  which  had  been  enlarged  by  incision,  was  stopped  with  a 
tent;  and  the  rest  of  the  dressings  and  the  situation  of  the  patient  so 
ordered,  as  to  remove  from  the  wound  all  such  pressure  from  within, 
as  might  disturb  the  cure."  "It  is  easy  to  conceive  that  this  opera- 
tion was  as  painful  to  the  patient  as  it  was  laborious  to  Mr.  A.; 
it  was  a  continued  dissection,  attended  with  danger  on  parts  not  well 
distinguished;  it  lasted  near  half  an  hour,  during  which  the  patient 
vomited  largely,  and  had  several  stools,  but  was  soon  composed  by 
1/2  oz.  of  diacodium"  (syrup  of  poppies)  "and  emollient  embroca- 
tions and  fomentations  frequently  apphed  warm  on  the  belly;  he 
was  blooded,  and  an  emollient  carminative  oily  clyster  was  ordered 
to  be  applied  in  the  evening;  but  as  he  was  easy,  and  the  belly  not 
tense,  that  was  omitted."  On  low  diet,  with  an  occasional  enema, 
the  case  progressed  favorably.  First  dressed  on  the  fourth  day,  the 
tent  was  not  removed  until  the  eighth ;  the  ligature  dropped  from  the 
appendix  on  the  tenth  day,  and  no  faecal  discharge  followed  it. 
The  would  then  healed  uninterruptedly,  care  being  taken  to  keep 
strong  and  constant  pressure  over  it  "as  well  to  fence  against  the 
intrusion  of  the  viscera  into  the  wound,  as  by  a  strong  incarnation 
and  cicatrix,  effectually  to  secure  the  patient  against  a  rupture." 
The  boy  was  discharged  in  good  health,  wearing  a  truss,  in  a  little 
over  a  month  from  the  date  of  the  operation.  Unfortunately, 
owing  to  neglect  of  proper  use  of  the  truss,  a  hernia  again  appeared, 
about  six  months  later. 

In  1757  Mestivier,  as  already  noted  in  the  previous  section,  saw 
the  case  of  a  woman,  in  whom  a  faecal  abscess,  already  fluctuating, 
and  pointing  to  the  right  of  the  naval,  was  opened  by  the  surgeon- 
major  of  the  hospital.  About  one  pint  of  pus,  "of  bad  quality," 
was  discharged;  and  although  the  patient  did  well  for  a  time,  she 
unexpectedly  died  when  the  resulting  ulcer  had  nearly  healed. 
This  is  the  first  concrete  instance  known  of  an  abscess  appen- 
diceal in  origin,  as  proved  by  the  autopsy,  being  opened  by  incision; 
all  previously  reported  cases  having  been  allowed  to  burst  of  their 
own  accord. 

The  medical  treatment  continued  practically  the  same  through- 
out the  eighteenth  century,  and  it  was  not  until  early  in  the  nine- 


History  of  Appendicitis  33 

teenth  century  that  an  advance  in  this  direction  was  made,  when, 
under  the  influence  of  the  teachings  of  Graves  and  Stokes,  of  Dubhn, 
opium  in  large  doses  was  administered  to  all  patients  who  presented 
evidences  of  peritonitis.  This  was  an  advance,  we  repeat,  though 
it  has  happily  been  superseded  by  a  still  greater  advance — early 
aseptic  removal  of  the  offending  organ.  It  is  true  that  Prescott  and 
a  few  other  practitioners,  had  employed  opium  in  doses  of  six  to 
eight  grains  daily,  and  apparently  prolonged  life  by  so  doing;  but 
their  object  was  merely  to  allay  pain,  and  the  routine  use  of  opium 
to  put  the  bowels  at  rest,  and  by  so  doing  to  minimize  the  amount 
of  fascal  extravasation,  and  encourage  the  formation  of  adhesions, 
though  employed  as  early  as  1823  by  Graves,  was  not  the  universal 
custom  for  some  twenty  years  later.  The  good  derived  from  the 
opium  treatment  was  undeniable;  it  was  the  greatest  good  except 
the  absolute  removal  of  the  inflamed  appendix.  It  encouraged  the 
formation  of  a  localized  suppuration  (the  only  intra-abdominal 
complication  successfully  amenable  to  surgical  treatment  in  those 
days),  and  even  when  this  end  was  not  attained,  it  rendered  peaceful 
a  death  which  without  its  use  would  have  been  a  lingering  agony  of 
torture. 

About  this  same  time  venesection  was  more  or  less  completely 
abandoned  for  local  bloodletting  by  leeches,  which  were  applied  to 
the  seat  of  pain,  and  sometimes  also  to  the  perineum,  in  numbers  of 
from  thirty  to  sixty  at  once,  several  times  daily. 

Peri-caecal  abscesses,  already  pointing,  are  known  to  have  been 
opened  in  181 5  and  in  1828  by  Dupuytren;  in  1832  by  Ahrt,  and  in 
1843  by  Willard  Parker,  of  New  York.  GrisoUe,  in  1839,  advised 
against  the  usual  custom  of  blindly  plunging  the  bistoury  into  the 
abscess  in  these  cases,  and  urged  the  importance  of  cautiously  dis- 
secting down  through  the  overlying  tissues,  because  a  coil  of  intestine 
might  intervene.  He  never,  moreover,  would  open  such  an  abscess 
until  fluctuation  was  present,  nor  until  it  had  become  adherent  to 
the  abdominal  walls. 

But  in  1848  occurred  the  greatest  surgical  advance  of  the  cen- 
tury, when  Hancock  performed  the  first  deliberate  laparotomy  for 
peri-appendicular  suppuration,  and  proposed  such  treatment  for 
all  cases  with  abscess  before  pointing  or  fluctuation  had  occurred, 
or  even  before  adhesions  to  the  anterior  abdominal  wall  had  formed. 
3 


34  Appendicitis 

This  was  looked  upon  by  many  as  a  procedure  foolhardy  in  the 
extreme,  in  spite  of  the  excellent  recovery  made  by  his  patient. 
The  details  of  the  case  are  as  follows:  A  woman  of  thirty  years, 
who  had  been  subject  for  some  years  to  pains  in  the  right  ihac 
region,  had  a  recurrence  of  thr's  pain  the  day  after  parturition.  She 
was  at  first  treated  with  sedatives;  then  an  enema;  then  leeches, 
with  warm  fomentations,  to  the  abdomen;  and  was  likewise  given 
opium,  calomel,  and  salines.  On  the  fifth  day  first  could  any  mass 
be  felt.  When  Mr.  Hancock  first  saw  her,  on  the  eighth  day  of  this 
attack,  the  right  iliac  region  was  so  sore  from  blistering  that  the 
physical  examination  was  unsatisfactory;  but  he  made  a  diagnosis 
of  trouble  around  the  caecum  or  the  appendix.  Two  days  later 
examination  was  possible,  and  showed  the  patient  sinking,  with 
symptoms  of  general  peritonitis,  and  a  deep  seated  mass  internal  to 
the  right  anterior  superior  iliac  spine.  There  was  no  evidence  of 
fluctuation.  Mr.  Hancock  thought  nevertheless  it  was  probable 
that  pus  was  present,  and  advised  cutting  down  on  this  mass,  to 
evacuate  any  matter  that  might  exist.  Under  chloroform  anaesthe- 
sia, he  therefore  made  an  incision  four  inches  in  length,  from  the 
iliac  spine  inward,  close  to  Poupart's  ligament;  and  on  opening  the 
abdominal  cavity  evacuated  a  quantity  of  excessively  offensive, 
turbid  serum,  with  fibrinous  flocculi,  mixed  with  air  globules  and 
patches  of  false  membrane.  The  patient  was  now  turned  on  her 
side,  to  allow  a  free  escape  of  the  matter;  a  poultice  was  applied, 
and  an  opiate  directed  to  be  administered.  After  a  tedious  illness 
of  two  weeks,  two  faecal  concretions  were  removed  from  the  slough- 
ing sinus.  These  were  faceted,  and  evidently  had  been  impacted 
in  the  appendix  and  had  escaped  from  it  by  ulceration.  "From  this 
date  she  got  well,"  adds  Mr.  Hancock. 

Not  until  1856  was  Hancock's  advice  repeated.  In  this  year 
Lewis  reiterated  the  importance  of  opening  abscesses  in  this  situa- 
tion early,  without  waiting  for  fluctuation  to  appear,  since  by  that 
time  many  patients  would  be  dead.  He  analyzed  forty  cases  of 
abscesses  in  the  right  iliac  region.  But  Willard  Parker,  in  1866, 
was  the  first  to  put  into  practice  again  this  method  of  treatment. 
He  advocated  operation  between  the  fifth  and  the  twelfth  day, 
after  adhesions  had  formed,  but  before  the  accumulating  pus  had 
ruptured  them. 


History  of  Appendicitis  35 

Most  of  these  operations  were  done  by  Hancock's  original 
incision;  and  some  less  daring  operators  incised  down  only  to  the 
transversalis  fascia,  and  then  either  allowed  the  abscess  to  break 
through  of  itself,  which  it  usually  did  in  the  course  of  a  few  hours; 
or  else  they  punctured  the  abscess  with  trocar  and  cannula,  and 
subsequently  dilated  the  sinus  thus  formed.  (See  Weber,  Whitall, 
Kolb.) 

The  introduction  of  the  drainage  tube  by  Chassaignac,  in  1859, 
materially  aided  the  cure  of  these  cases.  In  i86o*Munchmeyer 
first  made  a  counterincision  in  the  loin  to  facilitate  drainage. 

In  1865  Buck  opened  a  perityphlitic  abscess  pointing  in  the 
right  groin,  below  Poupart's  ligament;  and  from  this  opening  in 
the  thigh,  a  pin  subsequently  was  discharged,  evidently  being  the 
cause  of  the  disease. 

By  the  year  1883  the  number  of  operators  had  become  so  great 
that  Noyes  was  enabled  to  find  records  of  no  less  than  one  hundred 
cases  where  the  abscess  had  been  opened  by  puncture  or  incision. 
A  curious  operation  was  performed  in  this  year  by  Symonds:  by  a 
curved  incision  of  four  inches  in  length,  close  to  the  iliac  bone  and 
Poupart's  ligament,  working  across  adhesions,  he  removed  a  cal- 
culus from  a  chronically  affected  appendix  and  then  sutured  his 
incision  into  the  vermiform  process.  A  large  tube  was  placed  down 
to  the  wound  in  the  appendix,  this  organ  evidently  being  adherent 
to  the  parietal  peritoneum,  so  that  the  general  cavity  was  not  opened. 
The  patient  recovered  and  had  no  return  of  his  symptoms.  This 
method  of  procedure  was  planned  by  Dr.  Mahomed,  and,  as  will  be 
remembered,  carried  out  a  suggestion  made  by  Blackadder  as  early 
as  1824. 

In  1884  Kronlein  first  removed  the  appendix  for  acute  disease. 
He  employed  an  incision  through  the  linea  alba.  His  patient  did 
not  recover. 

Homans  in  1886  operated  on  a  case  of  appendicular  abscess, 
which  he  opened  across  the  general  peritoneal  cavity,  protecting  this 
from  the  contact  of  the  pus  as  well  as  he  was  able.  He  is  said  by 
Edebohls  to  have  employed  gauze  packs  for  this  purpose,  but  the 
original  article  makes  no  mention  of  them.     The  patient  recovered. 

On  April  21,  1887,  Weir  made  a  diagnosis  of  appendicitis,  and, 
after  opening  the  normal  peritoneal  cavity,  evacuated  an  appendic- 


36  Appendicitis 

ular  abscess  and  removed  the  appendix;  but  his  patient  did  not 
recover.  A  few  days  later  (April  25)  Thos.  G.  Morton  operated  on 
a  patient  with  peritonitis,  and  through  an  incision  ten  inches  long 
removed  part  of  a  perforated  appendix,  the  patient  recovering. 
In  the  original  report  of  this  case  it  is  not  stated  that  the  correct 
diagnosis  had  been  made  before  operation,  though  this  claim  was 
later  advanced. 

In  1887  Sands  successfully  closed  a  perforation  of  the  appendix 
by  suture,  wliile  in  1888  Treves  did  laparotomy  for  "relapsing 
typhlitis,"  and  found  the  omentum  adherent  to  the  appendix, 
which  was  thus  kinked.  Treves  therefore  cut  the  adhesion,  sutured 
a  tear  in  the  peritoneum  thus  made,  bared  the  convex  surface  of 
the  appendix  of  its  peritoneal  coat,  thinking  it  would  thus  contract 
new  adhesions  with  the  parietal  peritoneum  on  its  outer  side,  and 
so  be  held  straight,  and  closed  the  abdominal  wound  leaving  the 
appendix  in  its  new  position.  Recovery  ensued.  Being  encouraged 
by  his  experiences,  he  next  removed  the  appendix  for  recurrent 
attacks,  during  an  interval  of  quiescence,  closing  the  stump  of  the 
appendix  with  two  sutures,  and  then  stitching  a  flap  of  caecal  peri- 
toneum over  the  stump,  considering  this  a  much  safer  method  than 
merely  to  ligate  the  appendix  before  amputating  it,  as  had  been  done 
by  his  predecessors.     This  was  the  first  operation  in  an  "interval." 

In  1889  Tait  split  open  and  drained  an  inflamed  appendix, 
without  removing  it.  His  patient  recovered.  In  the  same  year 
Schiiller  first  successfully  closed  an  abdomen  without  drainage 
after  an  operation  for  appendicitis  in  which  the  peritoneal  cavity 
was  found  to  contain  turbid  serum.  Each  operation  is  an  instance 
of  a  custom  which  has  in  later  years  been  thought  more  honored 
in  the  breach  than  the  observance. 

Among  other  surgeons  who  operated  in  cases  of  this  kind  before 
1890  were: 

Adams,  Bacon,  Bailey,  Barlow  and  Godlee,  Barret,  Beach, 
Boardman,  Bontecou,  Briddon,  Bryant,  Buck,  Bull,  Burge,  Byrd, 
Cage,  Chamberlain,  Chaput,  Clarke,  Clay,  Cutler,  Deaver,  Ede- 
bohls,  Ely,  Freeman,  French,  Fries,  Gibney,  Gouley,  Grant,  Hall, 
Heath,  Hicks,  Hoffman,  Holden,  Howe,  Jarvis,  Kelsey,  Kohler, 
Kolb,  Krockowizer,  Leale,  Lewis,  Maclaren,  Mason,  McBurney, 
Merriam,  Mikulicz,  Miner,  Moore,  Mynter,  North,  Noyes,  Par- 


History  of  Appendicitis  37 

tridge,  Pierson,  Pinckney,  Polaillon,  Poncet,  Pooley,  Potter,  Post, 
Raub,  Regnier,  Stemen,  Stiegle,  Stimson,  Van  Buren,  Vander  Veer, 
Voss,  Walker,  Ward,  Weber,  Weinlechner,  Wey,  Whitall,  White, 
and  Woodard. 

When  an  abscess  was  not  pointing  the  usual  incision  was  through 
the  right  semilunar  line,  but  in  the  last  decade  of  the  century  this 
custom  was  rapidly  abandoned  for  either  the  incision  through  the 
right  rectus  muscle,  or  for  some  form  of  "muscle-splitting"  incision, 
which  was  at  first  considered  suitable  only  for  chronic  cases,  or  for 
"interval"  operations. 

The  simple  straight  incision  through  the  right  rectus  muscle  is 
said  by  Sprengel  to  have  been  used  first  in  1884  by  Gagen-Thorn, 
later  by  Ziegenspeck,  Ramsey  and  others.  Later  it  was  known  by 
Lennander's  name,  and  in  this  country  by  those  of  Edebohls  and 
Deaver.  This  incision  was  modified  by  Battle  in  1895,  by  Jalaguier 
and  by  Kammerer  in  1897,  and  by  Lennander  in  1898,  each  of  whom, 
apparently  independently,  proposed  to  draw  the  muscle  toward  the 
median  line,  after  opening  its  sheath  by  a  longitudinal  incision, 
without  separating  or  dividing  its  fibres.  The  original  "grid-iron" 
or  "muscle-splitting"  incision  was  proposed  by  McBurney  in  1893; 
and  has  since  been  further  modified  to  gain  more  room  in  case  of 
emergencies.  One  modification  was  that  proposed  by  Harrington 
in  1899  and  by  Wier  in  1900:  this  consists  in  dividing  the  rectal 
sheath  in  the  same  transverse  line  as  the  deeper  portion  of  the 
original  incision,  and  drawing  the  rectus  muscle  toward  the  median 
line.  Elliot  in  1896  described  an  incision  somewhat  similar  to 
that  of  McBurney,  except  that  the  superficial  as  well  as  the  deeper 
tissues  were  divided  in  a  transverse  direction;  he  proposed  to  enlarge 
this  by  cutting  up  and  down  in  the  semilunar  line,  or  by  extending 
the  cut  into  the  rectus  muscle.  Chaput  in  1905  described  a  similar 
incision.  The  transverse  incision  of  G.  G.  Davis  (1906)  opens  the 
sheath  of  the  rectus  muscle  anteriorly  and  posteriorly,  and  divides 
the  oblique  muscles  in  the  same  line. 

The  stump  of  the  appendix  in  the  earlier  operations  was  merely 
ligated.  Treves,  as  above  mentioned,  was  the  first  to  suture  the 
stump.  Dawbarn  introduced  in  1894  the  method  of  inverting  the 
stump  without  ligating  it,  by  a  purse-string  suture,  which  may  be  ap- 
plied even  before  the  appendix  is  removed,  and  tightened  afterward. 


38  Appendicitis 

There  are  three  therapeutic  measures,  introduced  to  the  notice 
of  the  profession  within  recent  years  which  merit  short  notice 
in  this  historical  review,  though  they  are  discussed  elsewhere 
in  the  volume.  In  chronological  order  these  are  (i)  the  Fowler 
position;  (2)  the  Murphy  method  of  operation  and  aftercare;  and 
(3)  the  Ochsner  treatment. 

The  late  Dr.  George  R.  Fowler  observed  for  some  time  previous 
to  the  publication  of  his  observations  in  1900  that  those  patients  un- 
der the  care  of  his  assistant  Dr.  R.  S.  Fowler  did  better,  who,  for 
the  purpose  of  diminishing  post-anaesthetic  vomiting,  were  treated 
by  having  the  head  of  the  bed  elevated  from  twelve  to  fifteen 
inches  above  the  floor,  and  he  therefore  adopted  this  position  as  a 
postural  treatment  in  cases  of  spreading,  diffuse,  or  general  periton- 
itis, as  a  matter  of  routine;  hoping  by  the  force  of  gravity  to  confine 
the  infectious  material  to  the  lower  portions  of  the  abdomen,  whence 
absorption  is  much  less  rapid  than  in  the  diaphragmatic  region.  It 
is  to  be  noted  that  these  patients  were  not  placed  in  the  sitting  posi- 
tion. The  true  "Fowler  position"  is  the  head  high  position  secured 
by  elevating  the  head  of  the  patient's  bed  from  ten  to  twenty  inches 
from  the  ground,  and  thus  changing  the  plane  of  the  bed  to  an  angle 
of  perhaps  fifteen  to  twenty  degrees  with  the  horizon.  Soon  after  this 
time  the  sitting  posture  was  introduced,  largely  through  the  influence 
of  Mayo  and  of  Robson  and  Moynihan,  with  the  idea  that  it  mechan- 
ically favored  drainage  of  the  stomach  after  gastro-enterostomy. 
Though  this  theory  has  since  been  abandoned,  the  benefit  derived 
from  sitting  these  patients  up  in  bed  is  incontestable,  and  this  posi- 
tion is  now  very  generally  adopted  in  cases  of  peritonitis  in  prefer- 
ence to  Fowler's  position. 

Murphy,  in  August  1904,  gave  his  conclusions  based  on  his 
experience  with  two  thousand  cases  of  appendicitis.  The  special 
feature,  with  which  his  name  is  associated,  was  the  treatment 
advocated  for  cases  of  spreading,  diffuse,  or  general  peritonitis 
Emphasis  was  laid  on  (i)  speedy  operation,  with  limited  intra- 
abdominal manipulations;  (2)  the  sitting  posture,  the  body  being 
raised  to  an  angle  of  thirty-five  to  forty- five  degrees;  and  (3)  the 
administration  of  large  quantities  of  saline  solution  (four  to  twelve 
quarts  in  twenty-four  hours)  by  the  rectum. 

Ochsner,  in  a  paper  based  on  an  experience  in  one  thousand 


History  of  Appendicitis  39 

cases  of  appendicitis,  read  October  14,  1904,  before  the  Tri-State 
Medical  Society,  offered  the  following  as  among  his  suggestions  for 
treatment  of  appendicitis,  with  a  view  of  reducing  the  mortality: 
Operation  in  all  interval  cases;  immediate  operation  in  all  acute 
cases  "provided  they  come  under  treatment  while  the  infectious 
material  is  still  confined  to  the  appendix;"  the  absolute  prohibition 
of  all  food  and  cathartics  by  mouth,  and  of  large  enemata;  gastric 
lavage  for  nausea,  vomiting,  or  gaseous  distention;  and  finally  that 
in  cases  coming  under  observation  after  the  infection  had  extended 
beyond  the  tissues  of  the  appendix,  especially  in  the  presence  of 
beginning  diffuse  peritonitis,  the  "starvation  treatment"  as  it  has 
been  called,  and  as  above  outlined,  should  always  be  employed 
"until  the  patient's  condition  makes  operative  interference  safe." 
Moreover,  he  urged  that  "in  case  no  operation  is  performed,  neither 
nourishment  nor  cathartics  should  be  given  by  mouth  until  the 
patient  has  been  free  from  pain  and  otherwise  normal  for  at  least 
four  days." 

The  two  most  important  articles  that  have  yet  appeared  dealing 
with  the  history  and  literature  of  appendicitis  are  those  of  Clado 
and  Edebohls,  both  of  which  have  been  freely  drawn  upon  in  the 
preparation  of  this  sketch. 


If,  then,  we  review  the  miscellaneous  facts  hitherto  set  forth 
in  rather  unpalatable  form,  we  find  that  the  existence  of  the  vermi- 
form appendix  was  unknown  until  the  sixteenth  century;  and  that 
from  the  mere  mention  of  it  in  anatomical  works  of  that  period,  a 
gradually  increasing  familiarity  with  its  structure  is  evident,  until 
the  beginning  of  the  nineteenth  century,  when  an  anatomical 
knowledge,  which  may  be  called  modern,  had  been  gained.  We 
find,  however,  that  the  symptoms  of  'a,  disease,  which  we  now  know 
as  appendicitis,  were  described  with  an  amount  of  accuracy  sufl&cient 
ior  recognition  at  the  present  day,  even  by  authors  of  classic  times; 
but  that  no  one  except  perhaps  Melier,  in  1827,  considered  disease 
of  the  vermiform  process  as  the  chief,  if  not  the  sole,  cause  of  these 
symptoms,  until  Matterstock  in  Germany,  and  Fitz  in  America 
proved,  over  a  generation  ago — the  former,  that  practically  all 
right  iliac  phlegmons  were  associated  with  a  perforated  appendix — • 


40  Appendicitis 

and  the  latter,  that  in  cases  of  so-called  typhlitis,  and  in  cases  of 
appendicitis,  the  symptoms  were  identical. 

That  a  knowledge  of  the  pathology  of  the  vermiform  appendix 
slumbered,  nay,  even  hibernated,  from  the  time  of  Melier,  until 
the  day  of  Fitz,  is  one  of  the  most  remarkable  things  in  the  whole 
history  of  medicine;  and  that  it  was  at  last  awakened  is  due  in  no 
small  measure  to  those  courageous  surgeons,  like  Hancock  and 
Willard  Parker,  who  determined  to  evacuate  perityphlitic  abscesses 
externally  before  these  abscesses  could  kill  the  patient  by  intra- 
peritoneal rupture;  and  to  all  those  operators,  notably  to  McBurney, 
Fowler,  Price,  Morris,  Richardson,  and  Murphy,  who,  inspired  by 
their  example,  determined  to  remove  the  offending  organ  before 
the  inflammatory  process  had  advanced  beyond  its  earliest  stages, 
at  a  time  when  the  general  peritoneal  cavity  was  yet  healthy,  and 
when  ablation  of  the  diseased  organ  meant  cure  without  hope  of 
relapse. 


ANATOMY. 

The  vermiform  appendix  of  man  is,  from  an  anatomical  stand- 
point, the  partly  developed  lower  end  of  the  caecum,  which  does 
not  undergo  the  same  degree  of  growth  and  distention  as  does  the 
rest  of  the  caecum.  In  the  embryological  development  of  the 
human  intestinal  tract  there  is  at  first  no  caecum  present,  the  original 
tract  consisting  of  a  straight  tube,  which,  for  purposes  of  description, 
has  been  divided  into  the  fore-gut,  the  mid-gut  and  the  hind-gut, 
and  is  attached  to  the  umbilicus  by  the  vitelline  duct,  sometimes 
persisting  in  the  adult  as  Meckel's  diverticulum.  This  attachment 
of  the  gut  to  the  anterior  abdominal  wall  pulls  the  formerly  straight 
tube  into  a  U-shaped  projection,  consisting  of  an  upper  and  lower 
limb.  At  the  end  of  the  sixth  week  of  intra-uterine  life  the  cascum 
is  well-marked,  budding  from  the  lower  limb  of  the  primitive  intes- 
tinal loop,  and  marking  the  division  between  the  small  and  the  large 
intestine.  The  lower  limb  of  the  loop  then  ascends  across  the  upper, 
past  the  umbilicus,  to  the  left  hypochondrium,  thence  across  to  the 
right  hypochondrium,  and  finally  about  the  end  of  the  sixth  month 
reaches  the  right  iliac  region,  though  even  at  birth  and  in  early 
childhood  the  caecum  is  placed  higher  than  in  adults.  The  caecum 
may  be  arrested  at  any  part  of  its  journey,  and  when  at  operation 
it  is  not  found  in  the  right  iliac  region  it  may  be  looked  for  in  either 
hypochondriac  region,  or  near  the  umbilicus.  A  number  of  instances 
are  recorded  of  its  position  in  these  abnormal  situations,  the  ascend- 
ing colon  or  this  and  the  transverse  as  well  being  absent.  Byron 
Robinson  in  an  analysis  of  autopsies  of  300  male  and  118  female 
bodies,  found  partial  non-descent  of  the  caecum  in  7  per  cent,  of  the 
former  and  3  per  cent,  of  the  latter.  Lennander  mentioned  the  case 
of  a  boy,  aged  sixteen  years,  in  whom  the  caecum  and  appendix 
were  found  in  the  left  hypochondriac  region,  lying  against  the 
spleen.     In  this  case  the  appendix  measured  nine  inches  in  length. 

Some  cases  are  recorded  where  the  appendix  is  said  to  have 
been  absent.     Byron  Robinson  figures  the  condition  found  by  him 

41 


42  Appendicitis 

at  autopsy  in  a  woman  of  fifty  years,  where  both  caecum  and  appen- 
dix were  congenitally  absent,  the  ileum  opening  into  the  ascending 
colon  without  perceptible  angulation.  I  have  never  found  the 
appendix  absent  on  the  operating  table.  ^ 

Further  studies  in  comparative  anatomy  support  the  physiol- 
ogist's claim  that  the  appendix  should  be  considered  as  a  lymph 
gland — ^as  the  abdominal  tonsil.  Berry  examined  the  csecal  apex 
or,  when  present,  the  vermiform  appendix  in  the  following  classes 
of  life:  Pisces,  Amphibia,  Aves,  and  Mammalia,  including  Marsu- 
pialia,  Edentata,  Ungulata,  Rodentia,  Carnivora,  Insectivora  and 
Anthropoidea.  Examination  of  the  skate  and  the  frog  was  negative ; 
but,  with  the  exception  of  a  few  others,  all  were  found  to  present  as 
their  one  common  characteristic  a  large  amount  of  lymphoid  tissue. 
In  the  cat,  pigeon  and  other  animals  with  short  caeca,  the  lymphoid 
tissue  tends  to  be  aggregated  in  distinct  masses;  when  the  caecum  is 
long,  as  in  the  domestic  fowl,  the  pig  and  the  sheep,  the  lymphoid 
tissue  is  diffused  throughout  the  caecum.  In  all  instances  the 
lymphoid  tissue  tends  to  be  better  marked  at  the  caecal  apex,  and 
to  be  comparatively  wanting  in  other  regions  of  the  intestinal  tract. 
His  conclusions  are : 

1.  Lymphoid  tissue  is  the  characteristic  feature  of  the  caecal 
apex.  The  vermiform  appendix  of  man  is,  therefore,  represented 
in  the  vertebrate  kingdom  by  a  mass  of  lymphoid  tissue,  situated 
most  frequently  near  the  caecal  apex. 

2.  As  the  vertebral  scale  is  ascended  this  lymphoid  tissue  tends  to 
be  collected  together  into  a  specially  differentiated  portion  of  the 
intestinal  canal — the  vermiform  appendix. 

3.  The  vermiform  appendix  of  man  is  not  therefore  a  vestigial 
structure.  On  the  contrary,  it  is  a  specialized  part  of  the  alimentary 
canal. 

Types  of  Caecum. — In  the  adult  the  caecum  develops  as  one 
of  four  types,  and  in  each  class  the  appendix  holds  a  different  posi- 
tion.    (Fig.  3.) 

I.  In  the  foetal  type  the  appendix  is  the  narrow  inferior  end 
of  the  conoid  caecum,  the  apex  of  the  cone  being  directly  continued 
into  the  appendix. 

*  Other  instances  where  the  appendix  was  absent  have  been  recorded  by  Fawcett 
(two  cases),  Ferguson,  Schridde,  Swan  (two  cases),  Dillard  and  Dorrance. 


Anatomy  43 

2.  The  second  type  consists  of  a  caecum  with  two  equally  large 
sacculi  at  its  inferior  termination.  The  appendix  arises  from  the 
lower  end  of  the  caecum,  between  the  sacculi,  which  are  separated 
by  the  anterior  longitudinal  band. 

3.  In  the  third  type  the  external  sacculus  is  large,  while  the 
internal  one  is  small,  thus  bringing  the  base  of  the  appendix  near 
the  ileo-caecal  valve.  In  addition,  the  anterior  wall  of  the  caecum 
grows  more  rapidly  than  the  posterior,  so  that  the  root  of  the  ap- 
pendix is  posterior. 

4.  In  the  fourth  and  last  type  the  internal  sacculus  has  disap- 
peared entirely,  and  the  base  of  the  appendix  is  attached  to  the 
caecum  posterior  to  the  receding  angle  between  the  ileum  and  caecum. 

The  first  type  of  the  caecum  is  very  rare;  the  second  is  not 
commonly  seen;  and  the  caecum  is  usually  of  the  third  type,  or 
partakes  of  the  character  of  the  third  and  fourth  types.  Woolsey 
says  that  type  one  is  found  in  only  2  per  cent,  of  cases;  type  two 
in  3  per  cent.;  type  three  in  90  per  cent.,  and  type  four  in  4  or  5  per 
cent.  According  to  Bryant's  statistics,  in  more  than  one-half  of  all 
cases  the  appendix  arises  from  the  posterior  surface  of  the  caecum 
about  one  inch  below  and  to  the  right  side  of  the  ileo-caecal  valve; 
and  in  nearly  all  cases  the  root  of  the  appendix  is  upon  the  postero- 
internal portion  of  the  caecum,  from  three-fourths  of  an  inch  to  one 
and  a  half  inches  from  the  ileo-csecal  valve.  Innumerable  observa- 
tions in  the  dissecting  room  and  at  the  operating  table,  moreover, 
have  proved  to  the  author  that  the  caecal  attachment  of  the  appendix 
is  almost  always  upon  the  postero-internal  portion  of  the  caecum. 
There  are,  however,  rare  instances  in  which  the  appendix  arises 
from  the  anterior  surface  of  the  caecum. 

In  cases  of  non-descent  of  the  caecum  the  appendix  holds  a  corre- 
spondingly abnormal  position,  and  under  such  circumstances  it 
may  lie  even  to  the  left  of  the  median  line. 

Length  and  Diameter  of  the  Appendix. — ^Although  the  aver- 
age length  of  the  appendix  is  from  8  cm.  to  9  cm.,  its  length  may 
vary  from  i  cm.  to  2^  cm.  When  the  appendix  is  long,  the  caecum 
is,  as  a  rule,  somewhat  shortened.  The  diameter  of  the  appendix 
is  that  of  a  goose-quill,  or  about  that  of  a  large  earthworm  (Holden) 
— ^from  3  mm.  to  5  mm. 

Peritoneal  Coat  of  the  Caecum  and  Appendix. — ^The  caecum 


44 


Appendicitis 


II 


III  IV 

Fig.  3. — The  Four  Primary  Types  or  C^cum. 


Anatomy  45 

is  usually  almost  completely  covered  by  peritoneum.  Its  anterior 
surface  is  entirely  invested  by  a  serous  covering;  a  small  area  on 
the  posterior  surface,  however,  is  frequently  left  uncovered  by  the 
divergence  of  the  two  layers  of  the  proximal  portion  of  the  meso- 
appendix.  In  rare  instances,  moreover,  the  caecum  has  been  found 
to  be  almost  entirely  retro-peritoneal,  the  whole  ascending  meso- 
colon, indeed,  being  practically  non-existent.  In  such  cases  the 
caecum  and  appendix  occupy  a  fairly  fixed  position;  whereas,  when 
the  meso-colon  and  meso-caecum  are  long,  the  caecum,  being  free  to 
move,  may,  with  the  appendix,  be  carried  by  the  ileum  even  into 
the  sac  of  a  left-sided  inguinal  hernia. 

The  peritoneum  nearly  invariably  invests  the  distal  portion  of 
the  appendix  completely,  but  throughout  the  proximal  half  or  two- 
thirds  there  is  usually  a  meso-appendix;  and  close  to  the  base  of  the 
appendix  there  is  frequently  on  the  posterior  or  inner  surface  a 
small  triangular  space  uncovered  by  peritoneum.  Sometimes  the 
meso-appendix  is  absent,  and  the  appendix  hangs  free  in  the  peri- 
toneal cavity;  or,  on  the  other  hand,  the  appendix  may  be  entirely 
subserous,  lying  beneath  the  peritoneum  in  almost  any  position. 
It  usually,  in  such  cases,  runs  up  behind  the  caecum,  either  to  its 
outer  or  inner  side,  being  situated  between  the  layers  of  the  meso- 
caecum  or  of  the  ascending  meso-colon;  but  has  also  been  found 
running  up  the  anterior  surface  of  the  caecum,  between  its  muscular 
and  serous  coats.  Pointing  downward  it  may  be  beneath  the  iliac 
or  pelvic  peritoneum,  lying  against  the  corresponding  fascia;  in  such 
cases  a  pelvic  abscess  may  occur,  which  will  be  extra-peritoneal,  or 
the  pus  may  burrow  along  the  external  iliac  vessels,  and  the  abscess 
point  in  the  thigh,  beneath  Poupart's  ligament. 

The  meso-appendix  is  a  double  layer  of  peritoneum,  similar  to, 
but  on  a  smaller  scale  than  the  mesentery,  from  the  under  or  left 
layer  of  which  it  is  derived.  It  is  either  triangular  or  quadrangular 
in  outline ;  when  the  former,  its  free  edge  may  be  considered  to  form 
the  base  of  the  triangle,  while  its  apex  is  at  the  root  of  the  appendix, 
and  the  two  sides  are  formed,  one  by  the  appendicular  attachment, 
and  the  other  by  its  origin  from  the  mesentery.  The  base,  or  free 
edge  of  the  meso-appendix  nearly  always  forms  an  acute  angle  with 
the  attachment  of  the  mesenteriolum  to  the  appendix;  and  in  some 
cases  is  continued  even  to  the  tip  of  the  appendix  as  an  exceedingly 


46  Appendicitis 

narrow  fringe,  almost  invisible  to  the  naked  eye.  When  quad- 
rangular in  outline,  the  fourth  side,  at  the  caecum,  is  usually  the 
shortest  of  all.  The  meso-appendix  usually  appears  to  be  too 
short  for  the  appendix,  thus  twisting,  curving  or  coiling  it  as  the 
mesentery  does  the  small  intestine  throughout  its  length.  The 
form  of  the  proximal  portion  of  the  meso-appendix  varies  slightly 
according  to  the  type  of  caecum:  where  this  is  of  the  first  or  second 
type,  the  proximal  part  of  the  meso-appendix  is  continued  as  the 
meso-caecum,  the  left  layer  of  which  is  continuous  above  with  the 
under  layer  of  the  mesentery  of  the  ileum,  and  below  with  the  left 
layer  of  the  meso-appendix;  the  right  layer  being  continuous  below 
with  the  corresponding  layer  of  the  meso-appendix,  and  above 
forming  the  right  layer  of  the  ascending  meso-colon.  The  upper 
portion  of  the  posterior  surface  of  the  caecum  is  usually  left  bare  of 
peritoneum  by  the  divergence  of  the  two  layers  of  the  meso-caecum; 
where  this  is  not  the  case,  abnormal  mobility  of  the  caput  coli  and 
appendix  ensues,  as  was  described  above.  In  the  third  type,  or  in 
types  which  are  intermediary  between  the  third  and  the  fourth,  the 
meso-caecum  appears  at  first  sight  to  be  absent;  search,  however, 
reveals  it,  though  shortened,  still  formed  by  the  diverging  layers 
of  the  proximal  portion  of  the  meso-appendix.  The  more  nearly 
the  caecum  approaches  the  fourth  type,  the  less  distinct  becomes  the 
meso-caecum,  since  in  this  type  the  meso-appendix  arises  entirely 
from  the  under  layer  of  the  mesentery,  and  the  proximal  part  of  its 
right  layer  is  continuous  with  the  serous  coat  of  the  caecum,  and  with 
the  peritoneal  lining  of  the  iliac  fossa,  the  junction  of  the  last  named 
two  portions  of  peritoneum  forming  the  outer  layer  of  the  meso- 
caecum,  while  its  inner  layer  is  so  short  as  to  be  practically  non- 
existent. As  the  form  of  caecum  approaches  the  first  type,  the  free- 
dom of  motion  of  the  appendix  increases,  so  that  at  operations  for 
their  excision,  appendices  of  this  type  are  more  easily  brought 
through  the  abdominal  wound  than  are  those  of  other  types,  since  a 
longer  meso-caecum  is  present.  Perforation  occurring,  as  it  occa- 
sionally may,  at  the  small  triangular  area  near  the  base  of  the  appen- 
dix, above  described  as  uncovered  by  peritoneum,  or  in  the  line  of 
attachment  of  the  meso-appendix,  would  open  into  the  interval 
between  the  two  layers  of  the  meso-appendix.  As  a  consequence 
of  such  perforation,  pus  may  pass  into  the  mesentery  and  thence  to 


Anatomy  47 

the  subperitoneal  areolar  tissue  of  the  iliac  fossa;  or,  at  the  proximal 
portion  of  the  meso-appendix,  the  pus  may  enter  the  post-cascal  are- 
olar tissue,  and  thence  gravitate  to  the  iliac  fossa;  or,  rarely,  it  may 
burrow  upward  behind  the  colon  and  simulate  perinephric  abscess. 

Between  the  layers  of  the  meso-appendix  are  found  the  arteries, 
veins,  nerves,  and  lymphatics  for  the  appendix,  together  with  areolar 
tissue  and  some  fat.  In  some  instances  the  iliac  vessels  pass  through 
the  meso-appendix,  thus  accounting  for  one  manner  in  which  collec- 
tions of  pus  in  the  right  iliac  fossa  may  find  their  way  beneath 
Poupart's  ligament  into  the  thigh.  In  the  female  the  meso-appendix 
sometimes  has  running  to  the  ovary  a  prolongation,  which  is  called 
by  Clado  the  appendiculo-ovarian  ligament.  It  conveys  an  addi- 
tional blood  supply  to  the  appendix,  and  will  be  described  in  more 
detail  later  in  connection  with  that  subject.  I  have  myself  never 
met  with  this  structure,  and  its  presence  is  denied  by  some  excellent 
authorities. 

The  meso-appendix  acts  also  as  an  appendicular  ligament,  the 
mobility  of  the  appendix  depending,  when  adhesions  are  absent, 
largely  upon  the  width  and  the  length  of  attachment  of  the  meso- 
appendix.  In  the  rare  cases  where  the  mesenteriolum  is  entirely 
absent,  the  appendix  is  freely  movable  in  the  abdominal  cavity. 

At  times  in  the  meso-appendix  may  be  found  an  opening,  in 
which  a  coil  of  small  intestine  has  been  known  to  have  become 
strangulated. 

Position  of  the  Appendix. — ^In  the  majority  of  cases  the  ap- 
pendix holds  one  of  eight  positions.  Dr.  Bristow  suggests  a  very 
simple  method  of  classifying  these  positions  and  directions.  This 
consists  in  locating  in  the  right  iliac  fossa  a  central  point  which 
represents  the  most  frequent  position  of  the  attachment  of  the 
appendix  to  the  caecum;  from  this  central  point  are  drawn  lines 
which  radiate  in  eight  different  directions.  To  indicate  the  course 
of  the  different  lines.  Fowler  has  modified  this  method  by  substitut- 
ing the  initial  letters  of  the  points  of  the  compass  for  the  numbers 
used  by  Bristow.  The  central  point  is  located  by  drawing  a  line 
from  the  anterior  superior  spine  of  the  ilium  to  the  umbilicus;  a 
point  on  this  line,  from  two  to  two  and  a  half  inches  from  the  an- 
terior superior  spine,  marks  the  position  of  the  root  of  the  appendix 
and  is  the  central  point  from  which  the  lines  are  drawn. 


48 


Appendicitis 


Although  the  appendix  may  occupy  any  of  the  eight  positions 
of  the  points  of  the  compass,  it  is  most  commonly  found  in  one  of 


5>iS 


Fig.  4. — Positions  of  the  Appendix. 
I.  Under  the  mesentery.     2.  In  the  pelvis.     3.  On  outer  side  of  caecum 

the  following:  (i)  It  may  lie  under  the  inferior  layer  of  the  mesen- 
tery, being  directed  toward  the  spleen — in  the  N.  E.  position;  (2) 
it  may  lie  on  the  ilio-pectineal  line  or  may  project  into  the  pelvis, 


Anatomy 


49 


Fig.  5. — Positions  of  the  Appendix. 
I.  Coiled  up  behind  caecum.     2.  Lying  down  and  out  on  iliacus  muscle.     3.  Abnor- 
mally long  appendix  extending  beyond  hepatic  flexure  of  colon. 


50  Appendicitis 

its  course  being  S.  or  S.  E.;  (3)  if  there  be  a  long  meso-appendix, 
it  may  lie  to  the  right  of  the  Ccecum  and  the  ascending  colon,  running 
upward,  in  a  northerly  direction  parallel  with  the  colon  and  over  the 
kidney  toward  the  right  lobe  of  the  liver;  (4)  it  may  lie  in  front  of 
the  colon  and  caecum,  its  course  generally  being  N.  or  N.  E.;  (5)  it 
may  lie  behind  the  caecum,  holding  generally  a  northerly  direction; 
(6)  if  the  appendix  has  a  long  and  wide  mesentery,  it  may  be 
directed  toward  any  of  the  other  points  of  the  compass,  freedom 
of  motion  generally  being  required  in  order  that  it  assume  any  of 
these  positions;  (7)  when  the  meso-appendix  is  short,  the  appendix 
may  be  coiled  upon  itself. 

Abnormally,  the  appendix  may  hold  a  position  in  either  of  the 
ileo-caecal  fossae;  it  may  lie  behind  the  peritoneum  and  behind  the 
caecum  and  may  be  in  contact  with  the  posterior  muscular  wall  of 
the  latter  (see  Fig.  7),  being  covered  in  this  position  by  the  peritoneal 
coat  of  the  caecum;  it  may  be  adherent  to  the  peritoneum  along  the 
right  border  of  the  caecum  and  ascending  colon  or  at  any  point  in 
the  neighborhood  of  the  caecum;  or  it  may  lie  in  the  inguinal  canal. 

It  seems  more  simple  and  practical,  however,  to  classify  the 
positions  of  the  appendix  as  follows:  (i)  Upward  or  upward  and 
outward,  lying  in  front  of,  behind,  or  upon  the  outer  or  inner  side 
of  the  caecum;  (2)  under  the  mesentery  and  directed  upward  and 
inward,  inward,  or  downward  and  inward  over  the  brim  of  the 
pelvis;  (3)  coiled  upon  itself  and  lying  under  the  caecum;  (4)  down- 
ward, lying  free  in  the  abdominal  cavity  under  the  caecum;  (5) 
outward,  lying  in  front  of  or  behind  the  caecum. 

When  the  appendix  is  directed  upward  or  upward  and  outward, 
and  lies  behind  or  upon  the  outer  side  of  the  caecum  or  colon,  an 
abscess  resulting  from  disease  of  this  organ  frequently  produces  its 
local  manifestations  in  the  loin  and  simulates  abscess  of  hepatic  or 
renal  origin.  When  the  inflamed  organ  is  directed  downward  and 
inward  or  downward  into  the  true  pelvis,  the  bladder  or  the  ovaries 
are  irritated.  The  following  are  from  statistics  collected  by  Bryant 
in  the  dissecting  room  from  144  subjects:  The  appendix  held  one 
of  the  upward  positions  in  relation  with  the  caecum  in  11  cases,  or 
less  than  8  per  cent. ;  it  was  under  the  mesentery  and  directed  upward 
and  inward,  inward,  and  downward  and  inward  in  92  cases,  or 
about  64  per  cent.;  it  was  coiled  upon  itself  under  the  caecum  in  i 


Anatomy- 


si 


Fig.  6. — Positions  of  tiie  Appendix. 
I.  Lying  on  top  of  mesentery  to  inner  side  of  caecum.     2.  Lying  on  outer  side  of 
ascending  meso-colon,  behind  caecum.     3.  Pointing  directly  downward,  below  caecum; 
the  tip  of  appendLx  in  contact  with  external  iliac  artery. 


52 


Appendicitis 


case,  or  less  than  i  per  cent.;  it  was  directed  downward  or  downward 
and  outward  or  lying  under  the  caecum  in  38  cases,  or  less  than 
27  per  cent.;  it  was  directed  outward  in  2  cases,  or  less  than  1.5  per 
cent. 


\ 


Fig.  7. — An  Unusual  Position  of  the  Appendix. 
Adherent  to  the  posterior  surface  and  covered  by  the  serous  coat  of  the  caecum. 

The  position  of  the  appendix  at  autopsies  has  also  been  inves- 
tigated by  Monks  and  Blake,  572  cases;  by  Boody,  509  cases;  and 
by^  Byron  Robinson,  418  cases.  Unfortunately  these  observers 
have  not  classified  their  experiences  in  the  same  way,  so  that  it  is 


Anatomy 


53 


difficult  to  make  a  synopsis  of  their  observations.  Robinson  has 
classified  the  various  positions  in  which  he  found  the  appendix, 
as  regards  its  relation  to  the  psoas  muscle;  while  the  other  authors 
divide  their  cases  into  groups  where  the  appendix  was  bound  down, 
down  and  in,  in,  up  and  in,  etc.  In  Robinson's  series  the  results 
may  be  presented  as  follows: 


Males — 300  Cases. 


Females — 118  Cases. 


37  per  cent 
46  per  cent 
23  per  cent 
20  per  cent 
18  per  cent 


.  .  .  hung  in  the  pelvis 48  per  cent. 

.  .  .on  the  psoas  muscle 20  per  cent. 

.  .  .to  the  left  of  psoas  muscle 20  per  cent. 

.  .  . retro-cajcal  35  per  cent. 

.  .  .to  right  of  psoas  muscle 28  per  cent. 


Irrespective  of  sex,  he  found  that  80  per  cent,  of  the  appendices 
were  to  the  right  of  the  psoas,  and  20  per  cent,  to  its  left. 

The  results  of  the  two  other  series  of  observations  may  be  com- 
bined in  the  following  table : 


Author. 

Number 
of  cases. 

Down, 
and  in. 

Down 

In. 

Up. 

Up 
and 
in. 

Up 
and 
out. 

Out. 

Down 
and 
out. 

In 
pelvis. 

Behind 
caecum. 

Monks 

and 

Blake 

572 

179 

79 

62 

52 

39 

29 

9 

5 

14 

104 

Boody 

509 

64 

42 

6 

43 

270 

84 

1 

Total 

1081 

243 

121 

68 

95 

309 

29 

9 

5 

14 

188 

Per  cent. 

22  .6 

II  .2 

6.3 

8.7 

28.5 

2.6 

0.8 

0-5 

1-3 

17-5 

Thus  it  is  seen  that  the  most  usual  postmortem  positions  are 
up  and  in,  and  down  and  in,  the  combined  percentages  of  these  two 
positions  from  the  above  table  being  over  51  per  cent.;  Bryant's 
figures,  quoted  above,  being  about  64  per  cent,  for  these  positions. 
In  my  own  operative  experience,  the  position  of  the  appendix  in  the 
great  majority  of  cases  has  been  down  and  out,  lying  in  the  sulcus 
on  the  outer  side  of  the  psoas  muscle;  but  my  observations  in  the 


54  Appendicitis 

dissecting  room  confirm  the  above  statistics,  that  is,  that  positions 
of  the  appendix  under  the  mesentery  are  most  common. 

Histology  of  the  Appendix. — ^Physiologically  the  appendix 
has  of  late  years  been  regarded  more  and  more  as  a  lymphoid 
structure,  some  even  claiming  for  it  the  role  of  a  gland,  under  the 
name  of  the  abdominal  tonsil.  Microscopically  the  resemblance  is 
fairly  close,  the  predominance  of  lymphoid  structures  in  both  organs 
being  obvious. 

The  coats  of  the  appendix  are  a  mucous,  a  submucous,  a  mus- 
cular and  a  serous.  Its  structure  is  very  similar  to  that  of  the  caecum 
and  the  lower  ileum. 

The  mucous  membrane  lining  the  appendix  is  composed  of  a 
single  layer  of  columnar  epithelial  cells,  placed  upon  a  basement 
membrane;  of  tubular  glands  reaching  down  to  a  delicate  mus- 
cularis  mucosae,  which  is  often  absent;  and  of  lymphoid  follicles. 
The  tubular  glands  and  the  lymphoid  follicles  are  embedded  in  a 
delicate  retiform  connective  tissue.  The  former  are  about  0.5  mm. 
in  length,  and  are  said  by  Lockwood,  who  is  the  best  recent  writer 
upon  the  subject,  to  be  bifid  and  sometimes  trifid  at  their  extremities, 
thus  giving  them  the  appearance  of  racemose  glands.  They  do  not 
extend  beneath  the  muscularis  mucosae,  as  above  mentioned,  whereas 
the  lymph  follicles,  some  of  them,  pierce  it  and  enter  the  submucosa, 
which  is  separated,  often  imperfectly,  from  the  mucosa  by  the 
muscularis.  The  lymphoid  tissue  in  which  the  tubular  and  lymph 
glands  are  embedded  becomes  in  inflammatory  conditions  obscured 
by  the  round-celled  infiltration,  which  may  completely  obliterate 
the  retiform  structure.  Thus  the  extent  to  which  this  delicate  con- 
nective tissue  is  hidden  by  the  inroad  of  the  inflammatory  cells  is  a 
rough  index  of  the  intensity  of  the  inflammation. 

At  the  caecal  orifice  of  the  appendix  there  is  sometimes  a  promi- 
nence of  the  mucous  membrane,  caused  by  increase  of  the  lymphoid 
tissue,  forming  a  small  valve,  well  described  by  Gerlach.  Under 
certain  circumstances  this  may  favor  occlusion  of  the  orifice.  In  a 
certain  proportion  of  cases,  moreover,  the  appendix  enters  the  caecum 
obliquely,  as  the  ureter  does  the  bladder,  and  thus  forms  a  sort  of 
valve. 

The  lymphoid  follicles  are  distinctly  visible  to  the  naked  eye, 
being  about  i  mm.  in  diameter.     In  shape  they  are  circular  or  oval, 


Anatomy  55 

and  are  almost  entirely  within  the  ring  formed  by  the  muscularis 
mucosas,  only  a  few  being  without  in  the  submucous  tissues.  Lock- 
wood  estimates  their  entire  number  in  the  average  appendix  at  from 
150  to  200  follicles.  In  the  centre  of  the  follicle,  which  stains  less 
deeply,  the  lymph  channels  are  more  capacious;  while  the  cortical  area 
stains  well,  and  is  quite  opaque.  The  base  of  the  follicle  reaches 
the  submucosa,  but  between  them  is  found  a  space  described  as  the 
follicular  or  basilar  lymph  sinus,  which  communicates  freely  with 
the  lymphatics  of  the  submucosa. 

The  submucosa,  beneath  the  muscularis  mucosae,  is  formed  of 
fibro-elastic  areolar  tissue.  Where,  as  is  usually  the  case,  the  mus- 
cularis is  absent  or  at  least  only  imperfectly  developed,  the  separa- 
tion of  the  submucosa  from  the  mucosa  is  very  indefinite.  The 
submucosa  contains  numerous  small  arteries  and  veins,  whic'h 
supply  the  mucous  membrane;  also  lymphatic  vessels,  a  few  lymph 
follicles,  and  a  small  quantity  of  fat.  The  thickness  of  this  layer 
is  extremely  variable. 

The  muscular  coat  consists  of  two  layers.  The  inner  is  a  fairly 
thick  layer  of  circular  fibres  which  at  times  constitute  fully  one-third 
of  the  entire  thickness  of  the  appendicular  wall.  This  layer  con- 
tains scarcely  any  connective-tissue  cells,  and  very  few  blood-vessels; 
hence  it  stains  deeply.  The  outer  layer  is  composed  of  longitudinal 
fibres,  not  so  thick  as  the  inner  layer,  and  in  places  nearly  absent, 
being  often  collected  into  longitudinal  bands,  somewhat  resembling 
the  analogous  arrangement  in  the  caecum.  Between  these  longi- 
tudinal bands  are  found  blood-vessels  and  lymphatics.  At  certain 
places  gaps  may  be  seen  in  the  muscular  coat,  allowing  the  sub- 
mucous and  subperitoneal  tissues  to  come  directly  into  contact  with 
each  other,  and  serving  for  the  transmission  of  blood  and  lymph 
vessels  from  the  meso-appendix  to  the  submucous  and  mucous 
coats.  Lockwood  has  called  special  attention  to  this  hiatus  mus- 
cularis, as  he  terms  it,  as  the  chief  avenue  of  infection  from  the 
deranged  epithelial  lining  of  the  appendix  to  the  subperitoneal 
tissues  and  the  peritoneum.  These  gaps,  of  course,  occur  only 
along  the  mesenteric  attachment,  and  near  the  caecal  end  may 
frequently  be  observed  with  the  naked  eye. 

The  peritoneal  coat  of  the  appendix,  like  similar  membrane  found 
elsewhere,  is  formed  by  a  fibrous  and  a  serous,  or  endothelial  layer. 


56  Appendicitis 

The  former  is  next  the  muscular  coat,  its  delicate  connective  tissue 
penetrating  among  the  longitudinal  bands  of  the  outer  layer,  and 
carrying  in  its  meshes  minute  blood-vessels,  nerves  and  lymphatics. 
The  endothelial  covering  consists  of  a  single  layer  of  irregularly 
polyhedral  cells  whose  serrated  margins  are  accurately  apposed. 
The  existence  of  actual  stomata  or  preformed  openings  at  inter- 
vals between  these  cells  is  now  denied  by  Muscatello  and  others. 
Lymphatics,  however,  course  immediately  beneath  the  endothe- 
lium which  offers  but  little  obstacle  to  the  escape  of  infection  into 
the  general  peritoneal  cavity  once  it  has  reached  the  subperitoneal 
lymph  channels. 

The  vascular  supply  of  the  right  iliac  fossa  is  derived  from 
tw^o  loops  formed  by  anastomosis  of  branches  of  the  superior  mesen- 
teric artery.  One  loop  is  formed  by  the  anastomosis  of  a  descending 
branch  of  the  colica  dextra  with  an  ascending  branch  of  the  ileo- 
colic artery,  and  the  other  loop  by  the  junction  of  descending 
branches  of  the  ileo-colic  with  terminal  branches  of  the  superior 
mesenteric  artery.  From  the  loop  first  described  arise  the  ileo- 
c£ecal  arteries,  known  from  their  relation  to  the  ileum  as  anterior 
and  posterior.  The  anterior  is  the  smaller,  and,  while  supplying 
the  anterior  surfaces  of  the  caecum  and  lower  ileum,  rarely  reaches 
as  far  as  the  appendix.  It  occasionally,  however,  sends  minute 
twigs  to  the  base  of  this  organ.  The  posterior  ileo-caecal  artery,  on 
the  other  hand,  is  the  chief  source  of  the  blood  supply  of  the  appen- 
dix. It  passes  down  behind  the  ileum,  close  to  the  caecum,  sends 
branches  to  the  back  of  the  lower  ascending  colon,  to  the  caecum, 
to  the  end  of  the  ileum,  and  to  the  appendix.  The  caecal  branch, 
mentioned  above,  coming  from  the  posterior  ileo-cascal  artery,  runs 
across  the  lower  inner  part  of  the  caecum,  near  the  origin  of  the 
appendix,  and  gives  ofiF  one  or  more  branches  to  the  base  of  the 
appendix.  During  foetal  life,  before  the  appendix  has  developed  a 
mesentery,  this  is  the  only  blood  supply,  and  hence  in  adult  life 
the  most  constant;  and  where  no  mesentery  to  the  appendix  exists  is 
even  in  adults  the  sole  source  of  blood  supply.  But  in  the  majority 
of  individuals  the  main  blood  supply  of  the  appendix  is  derived 
from  the  posterior  ileo-caecal  through  its  appendicular  branches,  which 
run  between  the  layers  of  the  meso-appendix.  These  branches 
are   usually   three   in   number,    the    largest   running  in   the   free 


Anatomy 


57 


Fig.  8. — ^\''ascular  Supply  of  the  Right  Iliac  Fossa. 


58  Appendicitis 

edge  of  the  mesenteriolum,  and  the  two  shorter  branches  supplying 
the  body  and  base  of  the  appendix.  It  is  a  well-known  fact  that 
perforation  is  prone  to  occur  at  the  point  where  the  meso-appendix 
ceases,  and  that  gangrene  is  especially  liable  to  attack  the  free  tip 
of  the  appendix,  where  it  has  no  mesentery.  These  facts  are 
sufficiently  explained  by  a  knowledge  of  the  blood  supply  as  above 
described. 

In  the  female  in  about  one  case  in  ten  (Clado)  there  is  an  appen- 
diculo-ovarian  ligament,  prolonged  outward  from  the  infundibulo- 
pelvic  ligament  to  the  meso-appendix,  Durand  identifies  it  with 
the  superior  fold  of  the  mesovarium,  or  "plica  vascularis"  of  Lock- 
wood.  This  fold  of  peritoneum  carries  a  small  artery  from  the 
ovarian  to  anastomose  with  the  mesenteriolar  appendicular  arteries, 
thus  in  some  females  giving  a  third  source  of  blood  supply  to  the 
appendix;  as  well  as  by  the  lymphatics  it  carries  allowing  ready 
transit  of  infection  from  the  adnexa  to  the  appendix,  and  vice  versa. 
As  already  remarked,  I  have  not  myself  met  with  this  structure, 
either  at  operations  or  in  the  dissecting  room;  and  its  existence  has 
been  denied  by  excellent  authorities.  (See  an  article  by  Coe,  in  the 
N.  Y.  Med.  Journ.,  1904,  ii,  254.) 

The  veins  of  the  appendix  are  the  most  dependent  of  the  branches 
of  the  portal,  the  sigmoid  and  haemorrhoidal  veins  being  excepted. 
This  fact,  together  with  the  thinness  of  their  walls  and  their  dis- 
proportionately large  lumens,  explains  their  proneness  to  engorg- 
ment.  These  veins  arise  in  the  submucous  and  the  subperitoneal 
tissues.  The  former  pass  out  with  the  arteries  and  lymphatics 
through  the  muscular  gaps  into  the  meso-appendix,  thence  to  a 
posterior  caecal  vein,  from  this  into  the  ileo-colic,  and  so  into  the 
portal  system.  The  subperitoneal  veins  pursue  mostly  the  same 
course,  but  a  few  empty  directly  into  the  caecal  veins. 

The  l)miphatics  of  the  appendix,  arising  as  has  been  described 
in  the  basilar  lymph  sinuses  in  the  mucous  layer,  pass  out  through 
the  hiatus  musculares  into  the  meso-appendix,  where  some  of  them 
pass  through  the  appendicular  lymph  gland,  which  is  not  always  to 
be  found.  They  then  pass  into  a  chain  of  lymph  glands  lying  in 
the  ileo-colic  angle,  along  the  inner  border  of  the  ascending  colon. 
Some  no  doubt  pass  into  the  mesenteric  lymph  glands,  but  the  former 
is  probably  the  more  frequent  route.     These  ileo-colic  glands  have 


Anatomy  ^g 

been  found  enlarged  in  malignant  disease  of  the  caecum,  and  have 
been  excised '  with  the  neighboring  intestine.  Moreover,  some 
lymphatics  from  the  appendix  empty  into  the  glands  along  the  ex- 
ternal iliac  vessels,  and  others  again  are  said  to  pass  by  way  of 
Clado's  ligament  to  the  broad  hgament,  the  pelvic  connective  tissue, 
and  the  internal  iliac  glands. 

The  nerves  of  the  appendix  are  derived  from  the  superior 
mesenteric  plexus  of  the  sympathetic  nerve,  the  branches  of  the 
plexus  which  accompany  the  ileo-colic  artery  sending  filaments  to 
the  appendix.  One  set  of  branches  supplies  the  peritoneal  and 
muscular  coats,  while  another  set  pierces  the  muscular  coats  at  the 
gaps,  and  supplies  the  blood-vessels  of  the  mucosa.  The  small 
intestine  receives  numerous  twigs  from  this  same  plexus  of  the 
sympathetic,  so  that  pain  from  the  appendix  may  be  referred  over 
a  wide  area. 

In  addition  to  the  knowledge  of  the  intrinsic  nerves  of  the  ap- 
pendix it  is  of  much  importance  to  consider  the  various  nerves  of 
the  abdominal  wall  through  which  referred  pain  is  felt.  This 
referred  pain  is,  of  course,  due  to  the  overflow  of  the  stimulation 
received  by  the  cells  in  the  spinal  cord  from  the  appendix.  That 
segment  of  the  spinal  cord  from  which  the  nerves  of  the  appendix 
are  derived  is  the  same  as  that  whence  the  eleventh  and  twelfth 
dorsal,  and  the  first  and  second  lumbar  nerves  arise.  Where  the 
irritation  to  the  cord  from  the  appendix  is  severe,  overflow  may 
occur  even  into  other  segments  of  the  cord;  but,  as  a  rule,  according 
to  Sherren,  referred  pain  occurs  in  the  area  of  distribution  of  the 
eleventh  dorsal  nerve,  less  often  in  that  of  the  tenth,  and  only  rarely 
in  that  of  the  twelfth  dorsal.  Branches  of  the  eleventh  and  twelfth 
dorsal  nerves  pierce  the  rectus  muscle  to  supply  the  skin,  one  of 
these  twigs  being  at  McBurney's  point,  and  thus  explaining  the 
very  great  frequency  of  pain  and  cutaneous  hyperalgesia  at  this 
situation.  The  first  lumbar  nerve  is  distributed  to  the  lower  ab- 
domen and  upper  part  of  the  thigh,  but  also  sends  a  twig  to  the 
tunica  vaginalis  testis,  thus  explaining  the  tenderness  of  the  right 
testicle  that  may  be  met  with  in  appendicitis.  The  reflex  instead  of 
being  referred  to  sensory  nerves  of  the  skin  may  be  referred  to  motor 
nerves  supplying  the  muscles  of  the  abdominal  wall,  the  erector 
spinae,  the  iliacus,  and  the  psoas  muscles  (viscero-muscular  reflex  of 


6o  Appendicitis 

Anterior  longitudinal  muscular  band  lleo-colic  fold 

Epiploic  appendages 
Ascending  colon 


Caecum 

lleo-colic  fossa 


lleo-colic  artery 

Peritoneum 


Mesentery 


True  pelvis 
External  iliac  artery 
Fig.  9. — The  Ileo-colic  Fossa. 


Anatomy  6i 

Mackenzie) .  As  the  flat  muscles  of  the  abdominal  wall  are  not  inner- 
vated by  a  single  trunk,  but  by  numerous  twigs  from  different  nerve 
trunks,  where  the  viscero-muscular  reflex  from  the  appendix  is 
referred  only  along  one  trunk,  merely  a  portion  of  the  muscle  will 
contract;  and  this  ribbon  or  band-like  contraction  when  in  the  rectus 
muscle  may  readily  be  mistaken  for  an  indurated  and  thickened 
appendix.  When  the  reflex  extends  to  the  ilio-psoas  muscle,  flexion 
of  the  thigh  is  produced,  and  hip  disease  may  be  simulated;  while 
vesical  symptoms  may  be  produced  by  spasms  referred  to  the 
bladder  or  to  its  sphincter,  retention  or  frequency  of  urination  being 
the  result  according  as  the  sphincter  is  or  is  not  affected. 

Peritoneal  Fossae. — ^Through  the  various  angles  and  projec- 
tions of  the  caecum  and  the  ileum,  fossae  are  formed  by  the  reflec- 
tions of  the  peritoneum  associated  with  these  parts  of  the  intestinal 
tract;  and  because  of  their  close  relation  with  the  appendix,  these 
fossae  may  play  an  important  role  clinically  in  inflammation  of  that 
organ.  Lockwood  and  Rolleston  have  called  special  attention  to 
these  fossae  and  have  so  carefully  described  them  that  I  give  their 
description :  They  are  three  in  number:  the  ileo-colic,  the ileo-caecal, 
and  the  subcaecal. 

The  ileo-colic  fossa  (Fig.  9)  is  a  peritoneal  pouch  situated  in 
front  of  the  mesentery  in  the  angle  formed  by  the  junction  of  the 
ileum  and  colon.  The  floor  is  formed  by  the  mesentery  and  some- 
times also  by  a  portion  of  the  ileum.  The  ileo-colic  fold  of  perit- 
oneum forms  the  upper  boundary  of  the  fossa,  and  sometimes  a 
partial  roof.  This  pouch  is  variable  in  size  and  depth,  and  on 
account  of  its  elevated  position,  does  not  play  a  very  important  part 
in  appendicitis. 

The  ileo-colic  fold  is  a  ridge  in  the  peritoneum  of  the  anterior 
surface  of  the  mesentery  and  is  formed  by  a  branch  of  the  ileo-colic 
artery  which  runs  through  the  ileo-colic  fold  and  passes  in  front  of 
the  termination  of  the  ileum. 

The  ileo-caecal  fossa  (Fig.  10)  is  a  peritoneal  pouch  situated 
behind  the  angle  of  junction  of  the  ileum  and  caecum.  To  expose 
it  both  the  ileum  and  caecum  must  be  elevated.  It  is  bounded 
on  the  right  by  the  mesentery  of  the  ascending  colon,  and  on  the 
left  by  the  mesentery  proper.  The  roof  is  formed  by  the  ileo-ccscal 
fold,  a  bloodless  fold  of  peritoneum  which  extends  from  the  free 


62 


Appendicitis 


lleo-caecal  fossa 
Longitudinal  nnuscula 
Ascending  colon 


)leo-caecal  fold 
eum 

Mesentery 


Caecum 

Vermiform  appendix 

Meso-appendixFiG.  lo.— The  IiSubcaseallteaBB 


True  pelvis 
External  iliac  artery 


Anatomy 


63 


Small  intestine 
•  Ascending  colon 
Epiploic  appendage 


eo  caecal  fold 
Ileum 


Under  surface 
of  mesentery 


Caecum 
Longitudinal  muscular  bar 

Abdominal  >^^. (ff.tie^tg^ Subcecal  Fos^.ubcaecal  fossa 


64  Appendicitis 

border  of  the  ileum  to  the  caecum  and  finally  joins  either  the  surface 
of  the  meso-appendix  or  the  under  surface  of  the  mesentery  near 
the  attachment  of  the  meso-appendix.  This  fossa  may  be  very 
deep  and  long,  and  at  times  may  extend  upward  behind  the  ascend- 
ing colon  as  far  as  the  kidney  and  duodenum.  The  mesentery  of 
the  appendix  sometimes  divides  the  fossa  transversely,  thus  forming 
two  fossae,  known  as  the  superior  and  inferior  ileo-caecal  fossae.  The 
ileo-caecal  fossa  is  important,  as  the  appendix  is  usually  found  in 
relation  with  it,  thus  explaining  why  this  location  is  often  the  site 
of  certain  products  of  appendicular  disease.  Consideration  of  the 
description  of  the  meso-appendix  and  meso-caecum  induces  the 
author  to  bound  this  fossa  as  follows:  on  the  right  by  the  caecum, 
meso-cascum,  and  meso-appendix;  on  the  left,  by  the  mesentery; 
and  above,  by  the  ileo-caecal  fold  and  the  ileum. 

The  subcaecal  fossa  (Fig.  ii),  as  its  name  implies,  is  immedi- 
ately under  the  caecum,  and  this  portion  of  the  bowel  must  be 
raised  in  order  to  view  it.  It  is  less  constantly  present  than  the  other 
fossae.  Its  mouth  is  found  behind  the  junction  of  the  caecum  with 
the  colon  and  the  fossa  here  separates  the  meso-colon  into  two 
double  folds.  On  account  of  its  elevated  and  external  position, 
clinically  it  does  not  play  a  prominent  part.  If,  however,  a  meso- 
caecum  were  always  present,  this  fossa  would  be  a  very  important 
one,  as  the  mouth  of  the  fossa  would  then  be  flush  with  the  tip  of 
the  caecum,  at  the  base  of  the  appendix.  Lockwood  and  RoUeston 
have  described  this  condition  as  occurring,  but  I  have  never  seen 
such  a  case.  I  prefer  to  describe  the  subcaecal  fossa  as  a  depression 
in  the  peritoneum  situated  beneath  the  caecum,  and  below  and 
external  to  the  meso-caecum  and  meso-appendix.  Berry  classifies 
these  fossae  as  peri-caecal  and  retro-colic.  Under  the  former  term 
he  describes  the  ileo-colic  and  the  ileo-caecal,  while  as  retro-colic  he 
gives  an  external  and  an  internal  retro-colic  fossa,  the  latter  being 
the  more  constant  of  the  two,  and  apparently  corresponding  to  that 
above  described  as  the  inferior  ileo-caecal  fossa.  It  is  situated, 
according  to  his  description,  between  the  inner  layer  of  the  ascending 
meso-colon  and  the  posterior  attachment  of  the  mesentery,  or  the 
mesenterico-parietal  fold.  He  bounds  it  thus:  (i)  In  front:  The 
posterior  wall  of  the  ascending  colon  and  sometimes  the  caecum. 
(2)  Behind:     The  posterior  abdominal  wall.     (3)  Internally:     The 


Anatomy  65 

mesenterico-parietal  fold.  (4)  Externally:  The  internal  parieto- 
colic  fold  (that  is,  the  inner  layer  of  the  ascending  meso-colon). 
His  external  retro-colic  fossa  seems  to  correspond  to  that  described 
here  as  the  subcaecal. 

The  appendix  may  occupy  any  of  these  fossae  but  it  is  commonly 
found  in  the  ileo-caecal  or  the  subcaecal  fossa.  On  account  of  the 
various  complications  that  may  arise  if  the  appendix  occupies  any 
of  these  fossae,  the  operator  may  be  led  to  form  an  incorrect  concep- 
tion of  the  true  state  of  affairs.  Thus,  at  times  the  appendix  may 
constitute  a  retro-peritoneal  hernia;  or,  if  the  appendix  occupy  one 
of  these  fossae,  and  the  mouth  of  the  fossa  should  close  over  it,  the 
organ  might  be  thought  to  be  absent.  Suppuration  of  an  appendix 
so  walled  in  would  be  entirely  circumscribed. 


THE  FUNCTIONS  OF  THE  APPENDIX. 

The  fact  that  the  appendix  can  be  removed  without  causing  any 
demonstrable  interference  with  the  functions  of  the  gastro-intes- 
tinal  tract  justifies  the  conclusion  that  the  appendix  is  not  a  funda- 
mental necessity,  but  does  not  prove  that  it  is  functionless. 

The  analogue  of  the  appendix  is  present  throughout  the  verte- 
brate kingdom,  represented  by  a  collection  of  lymphoid  tissue  in 
the  wall  of  the  caecum,  forming  the  so-called  ceecal  apex.  It  is 
only  in  the  higher  members  of  the  vertebrates  that  this  lymphoid 
tissue  occupies  a  distinct  structure,  the  appendix,  differentiated 
from  the  caecum.  This  differentiation  is  more  apparent  than  real. 
Though  grossly  the  appendix  is  quite  different  trom  the  caecum,  yet 
microscopically  it  is  seen  to  be  composed  of  the  same  number  and 
sort  of  layers,  innervated  and  vascularized  in  a  similar  manner. 
As  function  usually  parallels  cellular  construction  it  is  difficult  to 
escape  the  conclusion  that  the  function  of  the  appendix  is  substan- 
tially the  same  as  that  of  the  caecum  in  which  case  it  is  not  surprising 
that  it  is  not  indispensable.  There  is,  however,  a  difference  in 
structure  which  deserves  mention.  This  has  to  do  with  the  lymph- 
oid tissue  which  is  so  prominent  a  part  of  the  submucosa  of  the 
appendix  particularly  in  the  young.  The  caecum  is  provided  also 
with  lymphoid  follicles  though  not  to  the  same  degree  as  the  appendix. 
As  we  usually  conceive  of  lymphoid  tissue  as  essentially  a  protective 
mechanism,  it  is  possible  that  the  appendix  functionates  to  protect 
this  region  of  the  body  which  is  richest  in  bacteria  against  invasion 
and  injury.  The  fact  that  the  appendix  is  so  often  itself  inflamed 
does  not  militate  against  the  idea  since  it  is  the  part  of  lymphoid 
structures  at  many  points  in  the  body  to  receive  the  brunt  of  bac- 
terial invasion  and  suffer  the  greatest  injury.  The  lymphoid  tissue 
of  the  appendix  progressively  diminishes  throughout  life,  but  never 
under  normal  circumstances  disappears. 

There  can  be  no  doubt  that  the  caecum  and  appendix  are  true 
functionating  parts  of  the  digestive  apparatus  in  herbivora,  and 

66 


The  Functions  of  the  Appendix  67 

that  they  are  necessary  for  the  digestion  of  vegetable  matter.  In 
vegetable  feeders  the  food  is  only  partially  digested  when  it  reaches 
the  caecum  and  appendix,  where  digestion  is  completed,  the  latter 
organs  being  necessary  for  the  digestion  of  cellulose  particularly. 
The  caecum  is  never  empty  but  always  contains  a  remnant  of  the 
previous  meal,  which  is  left,  probably,  to  set  up  fermentation  when 
the  caecum  is  refilled.  In  some  animals,  ducks  for  instance,  there 
is  no  caecum,  but  two  appendices  which  serve  the  same  purpose. 

From  these  anatomical  facts  those  who  favor  the  view  that  the 
appendix  has  a  function,  argue  that  it  is  neither  a  vestigial  or  retro- 
gressing organ,  but  a  specialized,  functionating  portion  of  the  intes- 
tinal canal  in  man. 

The  following  clinical  facts  support  this  statement. 

MacEwen  observed  the  action  of  the  caecum  and  appendix 
through  a  wound  in  the  outer  wall  of  the  caecum.  There  was  free 
secretion  of  a  glairy  mucus,  alkaline  in  reaction,  which  became  more 
profuse  just  before  food  entered  the  caecum.  The  food  was  smeared 
with  the  secretion  from  the  appendix  and  mixed  with  that  in  the 
caecal  cavity. 

Hoefer,  in  repairing  a  wound  of  the  caecum,  saw  it  undergo 
vigorous  contractions  during  which  a  quantity  of  light  straw-colored 
fluid  escaped  from  the  appendix. 

Wood  reported  a  cyst  of  the  appendix  containing  six  ounces  of 
straw-colored  fluid.  From  the  history  of  the  case  it  was  inferred 
that  this  collection  had  formed  in  twenty-four  hours. 

Canal  makes  the  statement  that  the  appendix  secretes  daily 
six  ounces  of  light  straw-colored  fluid. 

These  cases  show  that  there  is  a  definite  secretion  from  the 
appendix.  Taking  this  fact  in  conjunction  with  the  structure  of 
the  appendix  and  its  well-known  usefulness  in  other  animals,  it 
seems  reasonably  certain  that  the  normal  human  appendix  has  a 
definite  function  closely  associated  with  caecal  digestion  with  pro- 
tection against  infection  possibly. 

Keith  considers  the  evidence  so  strong  that  he  thinks  it  probable 
that  all  the  food  has  to  pass  through  the  appendix  for  complete 
caecal  digestion.  This  is  hardly  credible  on  account  of  the  relative 
size  of  the  appendix  and  the  caecal  contents. 

Metchnikoff  says  that  not  only  has  the  appendix  been  preserved 


68  Appendicitis 

long  after  its  function  has  disappeared,  but  that  the  human  cascum 
is  degenerating  and  the  whole  of  the  large  bowel  is  of  comparatively 
little  use  to  the  economy.  In  support  of  the  statement  that  the 
appendix  has  no  function  he  quotes  Darwin's  observation  that  all 
rudimentary  organs  show  a  congenital  lack  of  the  power  of  resist- 
ance and  are  frequently  the  seats  of  disease.  That  the  caecum  is 
degenerating  he  considers  evident  from  the  fact  that  it  is  little  devel- 
oped in  comparison  with  herbivora,  and  that  in  the  human  embryo 
it  is  relatively  better  developed  than  in  the  adult. 

Metchnikoff  also  thinks  that  there  are  strong  reasons  for  saying 
that  the  whole  of  the  large  bowel  is  useless  and  harmful,  a  survival 
from  ancestors  who  fed  on  crude  and  rough  materials.  Our  food 
now  is  easily  digested,  and  except  for  the  absorption  of  fluid  the 
caecum  and  large  intestine  have  no  function.  He  instances  many 
cases  of  fistula  from  the  lower  end  of  the  ileum  completely  cutting 
out  the  rest  of  the  bowel,  existing  for  several  years  without  causing 
any  interference  with  health.  Being  a  reservoir  of  waste  and 
putrefaction  the  large  intestine  is  a  manufactory  of  products  harmful 
to  the  organism  and  it  must  therefore  be  regarded  as  an  organ  that 
has  survived  its  period  of  usefulness  to  become  "harmful  to  man's 
health  and  life." 

These  views  are  not  necessarily  dissonant.  We  can  believe 
that  the  appendix  has  a  function  and  yet  that  it  is  essentially  ves- 
tigial in  character  and  that  its  potentialities  for  harm  are  greater 
than  its  capability  for  good. 


CLINICAL  iETIOLOGY. 

The  aetiology  of  appendicitis  may  be  appropriately  divided  into 
the  clinical  aetiology  and  the  pathogenesis;  the  latter  will  be  dis- 
cussed in  the  chapter  on  the  pathology  of  the  affection.  From 
the  clinical  point  of  view,  the  aetiological  factors  are  either  predis- 
posing or  exciting,  or  both. 

Of  the  predisposing  causes,  the  most  important  are  age,  sex, 
nationality,  season,  previous  attacks  of  appendicitis,  and  certain 
other  diseases.  Of  the  exciting  causes,  the  most  important  are 
exposure,  disturbance  of  digestion,  and  certain  other  diseases. 
Under  different  circumstances,  some  of  the  latter  may  act  as 
both  predisposing  and  exciting  factors. 

Age  is  a  predisposing  cause  of  moderate  importance.  Although 
appendicitis  is  most  common  in  individuals  between  ten  and  thirty 
years  of  age,  about  15  per  cent,  of  all  cases  occur  in  persons  under 
fifteen  years.  The  youngest  patient  in  whom  I  have  encountered 
the  disease  was  less  than  one  year  old;  the  oldest,  over  ninety 
years.  A  case  of  gangrenous  appendicitis  found  at  autopsy  on  a 
seven  weeks'  old  infant,  is  reported  by  Blumer  and  Shaw.  Manley 
mentions  as  the  youngest  patient  operated  on  a  baby  aged  sixty-one 
days.^  The  marked  susceptibility  of  young  adults  to  appendicitis 
is  dependent,  in  the  first  place,  upon  the  numerous  disturbances  of 
the  gastro-intestinal  tract,  due  to  dietary  indiscretions,  that  occur 
during  this  period  of  life;  and,  secondly,  to  the  proneness  to  inflam- 
tion  of  the  adenoid  tissues  throughout  the  body  during  adoles- 
cence. Analogy  is  found  in  the  predominance  of  lesions  of  the 
tonsils  and  of  the  cervical  and  mesenteric  lymph  glands  during 
the  period  of  development.  Reason  for  the  relative  exemption 
from  inflammation  of  the  appendix  during  advanced  life  is  found, 

*  Jackson,  Am.  Jour.  Med.  Sc,  1904,  cxxvii,  710,  has  recorded  a  case  of  supposed 
prenatal  appendicitis. 

69 


70  Appendicitis 

not  only  in  a  more  judicious  mode  of  life,  but  also  in  the  atrophy 
of  the  adenoid  tissues  of  the  appendix.  This  in  the  majority  of 
cases,  commences  at  about  the  thirtieth  year.  It  may,  however, 
begin  earlier  or  may  be  postponed  until  a  later  period. 

Sex  is  a  predisposing  cause  of  considerable  importance.  Appen- 
dicitis was  formerly  thought  to  be  very  much  more  common  in 
males,  but  recent  observations  tend  to  show  that  this  is  not  the  case. 
In  a  paper  by  Dr.  Floyd  W.  McRae  the  following  statistics  are 
quoted:  Einhorn,  in  18,000  successive  autopsies,  found  perforating 
appendicitis  in  55  per  cent,  of  males  and  in  57  per  cent,  of  females; 
Robinson  in  128  autopsies  found  evidences  of  past  peritonitis  on 
and  about  the  appendix  in  68  per  cent,  of  female,  and  in  56  per 
cent,  of  male  bodies.  Bland-Sutton,  however,  is  quoted  as  stating 
that  appendicitis  is  three  times  as  frequent  in  males  as  in  females. 
In  previous  editions  of  this  work  it  was  stated  that  about  80  per 
cent,  of  all  cases  of  appendicitis  occur  in  males — that  is  to  say, 
that  it  is  four  times  as  frequent  in  males  as  in  females.  This  ratio 
is  probably  too  high,^  but  we  cannot  accept  autopsy  reports  as 
final  in  the  records  of  any  disease,  since  there  are  undoubtedly 
some  cases  that  do  not  come  to  autopsy  even  if  the  patients  die. 
Dr.  O.  Hermes  is  quoted  in  the  above  paper  as  stating  that  in  671 
cases  gathered  from  various  sources  27  per  cent,  were  in  women; 
that  Sonnenberg  found  that  40  per  cent,  of  his  cases  were  in  women; 
and  that  of  Talamon's  cases  35  per  cent,  were  in  females.  Hermes 
calculated,  moreover,  that  of  1577  cases  of  appendicitis  occurring 
in  Berlin  40  per  cent,  were  in  females.  McRae  calls  attention 
to  the  liability  of  abdominal  pains  in  women  being  referred  to  the 
sexual  organs  under  the  vague  caption  of  "inflammation  of  the 
tube  or  ovary,"  and  he  asserts  that  in  almost  all  his  cases  the  attack 
of  appendicitis  occurred  at  or  near  the  menstrual  period.  In  15 
operations  for  appendicitis  in  females,  which  he  reports,  he  observed 
4  cases,  over  25  per  cent.,  in  which  there  was  also  distinct  disease 
of  the  right  tube  and  ovary. 

*  In  the  last  three  thousand  cases  of  appendicitis  in  adults  operated  on  by  myself 
there  were  61.87  percent,  male,  38.13  per  cent,  females.  In  the  last  two  hundred 
children  operated  on  178  were  males  and  22  females,  being  89  per  cent,  boys  and  11 
per  cent,  girls. 


Clinical  ^Etiology 

NINE  THOUSAND  OPERATIONS  FOR  APPENDICITIS. 


71 


Sex 


Acute 


Chronic 


Total 


Males 

Females 

Total 

Percentage,  males . . 
Percentage,  females. 


2941 
1821 


4762 
61.76 
38.24 


1802 
2436 

4238 
42.52 
57  48 


4743 
4257 


9000 

52-7 
47-3 


II. 


Age 


Chronic 


Total 


Per  cent. 


One  to  ten 

Eleven  to  twenty 

Twenty-one  to  thirty . 
Thirty-one  to  forty . . . 

Forty-one  to  fifty 

Fifty-one  to  sixty 

Sixt\--one  to  seventy . . 
Seven tj'-one  to  eighty. 

Total 


247 
1622 

1564 
790 

350 

147 

34 


4762 


53 

955 

1809 

937 

370 

89 

24 


4238 


300 

2577 

3372 

1728 

720 

236 

58 

9 

9000 


3-33 
28.63 

37  48 
19.20 
8.00 
2  .62 
0.64 
o.io 


III. 


Month 


Acute 


Chronic 


Total 


Per  cent. 


January . . . 
February . . 

March 

April 

May 

June 

July 

August. . . . 
September . 
October . .  . 
November . 
December . 


358 
376 
424 

413 
455 
438 
467 
401 
376 
405 
326 

323 


405 
337 
424 

436 
385 
389 
402 
218 
332 
376 
287 

247 


763 

713 


846 
827 
869 
619 
708 
781 
613 
570 


48 
92 
42 
43 
33 
19 
66 
88 

87 
68 
81 
33 


Total. 


4762 


4238 


9000 


72  Appendicitis 

NINE  THOUSAND  OPERATIONS  FOR  APPENDICITIS. — Continued. 


TV.                     Seasons 

Acute 

Chronic 

i 

Total 

i 
Per  cent. 

Spring  (March,  April,  May) 

1292 
1306 
1 107 
1057 

1245 
1009 

995 
989 

2537 
2315 
2102 
2046 

28.19 
25.73 
23.34 
22 . 7.1 

Summer  (June,  July,  August) 

Autumn  (Sept.,  Oct.,  Nov.) 

Winter  (Dec.    Jan.,  Feb.) 

Total 

4762 

4238 

9000 

100.00 

The  greater  attention  which  has  recently  been  paid  to  the 
anatomy  of  the  right  iHac  region  has,  moreover,  convinced  some 
surgeons  that  extension  of  inflammation  from  the  appendix  to 
the  adnexa  or  from  the  tube  and  ovary  to  the  appendix,  by  way  of 
Clado's  ligament  and  its  contained  structures,  is  considerably 
more  frequent  than  was  formerly  supposed.  Coe  thinks  that 
appendicitis  in  females  is  coincident  with,  or  a  consequence  of, 
adnexal  disease  in  30  per  cent,  of  such  cases. 

In  view,  therefore,  of  all  these  facts,  it  will  be  well  perhaps  to 
modify  the  statements  formerly  made  as  to  the  relative  immunity 
of  the  female  sex,  and,  while  not,  on  the  other  hand,  admitting  as 
some  would  claim,  that  the  disease  in  question  is  actually  more 
frequent  in  women,  to  say  that  appendicitis  occurs  nearly  as  often 
in  females  as  in  males;  but  that  it  is  apt  to  be  overlooked  in  the 
former,  being  attributed  frequently  to  some  menstrual  disturbances, 
or  even  at  operation  being  thought  secondary  to  tubo  ovarian 
infection. 

Karrenstein  after  exhaustive  investigations  reached  the  con- 
clusion that  appendicitis  is  equally  frequent  in  men  and  in  women. 

Nationality  is  not  so  important  an  aetiological  factor  as  it  was 
presumed  to  be  some  time  ago.  It  seems,  however,  to  be  of  some 
importance;  or  perhaps  what  we  consider  nationality  in  this  con- 
nection is  mere  environment.  For  a  time  it  seemed  that  appendicitis 
was  disproportionately  common  in  the  United  States,  the  number 
of  cases  recorded  in  this  country  far  exceeding  those  reported  in 
Great  Britain  and  Continental  Europe.  Recently,  however,  in 
France,  Germany  and  Austria,  and  to  a  less  extent  in  Great  Britain, 


Clinical  ^Etiology  73 

the  early  stages  of  the  affection  have  received  deserved  attention, 
and  the  disease  is  now  recognized  as  of  common  occurrence.  It 
seems,  nevertheless,  to  be  especially  common  in  this  country,  and 
this  is  probably  due  to  well-known  and  widespread  dietetic  indis- 
cretions, particularly  hurried  eating  and  insufficient  mastication. 
Whether  those  of  foreign  birth  residing  in  this  country  who  practise 
temperate  habits  of  eating  are  less  predisposed  to  the  disease  than 
those  actively  participating  in  all  the  phases  of  hurried  American 
life  is  not  definitely  determined. 

Season  exerts  little  influence  as  an  astiological  factor.  Appen- 
dicitis is  probably  more  common  in  Summer  than  it  is  in  Spring 
and  Autumn  and  Winter.  The  differences,  however,  are  slight,  and 
those  that  do  exist  are  probably  due  to  the  greater  frequency  of 
intestinal  disorders  in  Spring  and  Summer  than  in  Autumn  and 
Winter. 

Of  other  diseases  that  predispose  to  appendicitis  may  be  men- 
tioned constipation,  gastro-enteritis,  dysentery,  typhoid  fever, 
influenza,  saturnism,  etc. 

Constipation  has  by  some  observers  been  considered  to  play  a 
somewhat  important  part  in  the  causation  of  appendicitis.  This 
causative  relation  is  however  most  probably  more  an  apparent  one 
than  a  real  one.  In  other  words,  the  constipation  and  the  appen- 
dicitis both  have  as  a  more  remote  causative  factor  the  existence  of 
a  chronic  enteritis. 

Gastro-enteritis  with  diarrhoeic  attacks  is  probably  of  more 
importance  than  constipation  in  theaetiology  of  appendicitis,  especially 
in  children.  Indeed,  in  many  cases  attacks  of  indigestion  seem  to  be 
the  direct  exciting  cause  of  the  disease.  The  subacute  or  more 
chronic  gastro-enteritis  is  probably  of  significance  in  that  the  appendix 
is  prone  to  participate  in  morbid  conditions  that  implicate  the 
general  intestinal  tract.  Catarrh  of  the  intestinal  mucous  membrane 
may,  and  probably  often  does,  spread  to  the  lining  of  the  appendix; 
but  such  is  the  mildness  of  the  pathological  alterations  that  they  do 
not  engender  any  clinical  manifestations.  At  times,  however,  they 
may  progress,  either  of  their  own  accord  or  following  the  advent  of 
some  exciting  cause,  and  an  acute  attack  of  appendicitis  may  super- 
vene. Under  other  circumstances  catarrhal  changes  of  mild  degree 
persist,  and  lead  to  chronic  catarrhal  or  interstitial  appendicitis,  with 


74  Appendicitis 

or  without  clinical  symptoms.  At  all  events,  in  many  cases  of  chronic 
appendicitis  careful  inquiry  into  the  past  history  of  the  patient  will 
elicit  symptoms  of  chronic  intestinal  catarrh,  which  either  may  have 
inaugurated,  or  may  have  been  inaugurated  by,  the  appendicitis,  and 
which  does  not  subside  until  after  excision  of  the  offending  organ. 

E.  Franke  calls  attention  to  the  findings  at  autopsy  in  a  series  of 
fatal  cases  of  gastro-enteritis  in  children.  He  states  that  the  appen- 
dix was  invariably  found  to  be  greatly  involved  particularly  at  its 
distal  extremity.  He  reached  the  conclusion  that  this  condition  not 
totally  subsiding  would  give  rise  to  a  true  appendicitis  in  later  life. 

Dysentery  is  also  of  aetiological  significance,  because  of  the  pre- 
disposition of  the  appendix  to  participate  in  lesions  of  the  intestinal 
tract.  These  lesions,  of  course,  consist  mainly  of  ulceration,  and  it 
is  the  consequent  cicatrices  that  are  of  such  extreme  significance 
in  the  subsequent  development  of  appendicitis.  The  significance 
of  .these  cicatrices  will  be  dealt  with  in  the  section  on  the 
pathogenesis. 

Typhoid  fever  is  one  of  the  remote  causes  of  appendicitis,  and, 
at  times,  also  one  of  the  direct  causes  of  the  affection.  It  has  been 
proved  conclusively  that  lesions  of  the  appendix  are  of  common 
occurrence  in  typhoid  fever.  For  the  most  part  these  consist  of 
catarrhal  alterations,  and  of  swelling,  congestion,  and  oedema  of  the 
adenoid  follicles  of  the  organ.  Not  uncommonly,  however,  ulcera- 
tion occurs,  and  runs  a  course  precisely  similar  to  analogous  condi- 
tions in  other  portions  of  the  intestinal  tract;  that  is,  the  ulceration 
may  go  on  to  perforation;  or  regeneration,  organization,  and  cicatriza- 
tion may  follow  the  ulcerative  process.  As  a  consequence  of  the 
resultant  cicatrix,  more  or  less  occlusion  of  the  lumen  of  the  organ 
may  supervene,  and,  as  will  appear  later,  this  is  one  of  the  most 
important  factors  in  the  subsequent  development  of  appendicitis. 
In  certain  cases  of  chronic  appendicitis  a  history  of  previous  intestinal 
disorder  can  readily  be  elicited.  This  may  consist  of  intestinal 
indigestion,  vague  pains  in  the  abdomen,  etc.,  the  origin  of  which 
can  often  be  traced  to  an  attack  of  typhoid  fever  that  may  have 
occurred   months   or   years   previously. 

This  is  illustrated  by  the  following  case: 

Miss  I.  M.  W.  was  first  troubled  with  a  mucous  discharge  from  the  bowel 
in  the  summer  of  i88g.     At  this  time  she  had  an  illness  which  was  attended 


Clinical  ^Etiology  75 

by  frequent  watery  and  sometimes  bloody  stools,  and  which  was  called  typhoid 
fever.  She  was  confined  to  bed  for  three  weeks  and  made  a  tedious  recovery. 
Since  that  time  she  has  been  the  subject  of  attacks  of  catarrhal  enteritis,  which 
come  on  at  intervals,  the  longest  interval  being  four  months.  These  attacks, 
which  seem  to  be  induced  by  exposure  to  cold,  unusual  exertion,  sea-sickness, 
etc.,  were  less  frequent  in  the  autumn  and  early  winter,  after  change  of  air  and 
rest  during  the  summer,  than  at  any  other  season.  During  the  interval  she 
was  well.  In  June,  1S93,  she  had  an  attack  that  lasted  three  weeks.  When 
seen  for  the  first  time,  vague  pains  were  present  in  the  right  iliac  fossa  and  a 
distinctly  enlarged  and  tender  appendix  could  be  palpated.  At  operation  there 
were  no  peritoneal  adhesions,  but  the  appendix  was  indurated  and  contained 
pus.  The  mucosa  and  submucosa  were  thickened  and  presented  evidences 
of  chronic  catarrhal  inflammation.  Recovery  was  prompt  and  uneventful, 
and  was  followed  by  the  entire  disappearance  of  the  symptoms  previously 
complained  of. 

Influenza  seems  to  exert  a  predisposing  influence  in  the  pro- 
duction of  appendicitis,  probably  because  of  the  intestinal  lesions 
to  which  it  gives  rise.  These  changes  may  extend  to  the  mucous 
membrane  and  lymphoid  structures  of  the  appendix;  or  such  may 
be  the  swelling  of  the  appendicular  orifice  produced,  that  drainage 
is  effectually  prevented  and  appendicitis  results;  or  the  influenza 
bacillus,  gaining  access  to  the  appendix,  may  directly  excite  inflam- 
mation of  this  organ.  Adrian  found  influenza  bacilli  in  a  peri- 
appendicular abscess.  The  prevalence  of  this  disease  as  a  pandemic 
may  account,  in  part,  for  the  great  number  of  cases  of  appendicitis  in 
recent  years.  Observations  tending  to  confirm  this  statement  have 
recently  been  recorded  by  Marvel,  who  showed  that  influenza  and 
appendicitis  have  of  late  years  increased  almost  pari  passu.  He 
quotes  a  number  of  authors,  including  Finney  and  Hamburger, 
Winternitz,  Adrian,  Perer,  Lucas-Championniere,  Schultes,  and 
Sonnenburg,  all  of  whom  considered  influenza  an  efficient  cause  of 
certain  cases  of  appendicitis.  Rostowzen,  however,  who  investi- 
gated 3096  cases  of  appendicitis  in  St.  Petersburg  from  1890  to  1902, 
concludes  that  influenza  plays  but  little  part  in  its  causation,  and  also 
that  season  has  no  influence  upon  the  incidence  of  appendicitis. 

Tonsillitis. — Kelynack  is  said  to  be  the  first  author  to  report 
a  case  of  fatal  appendicitis  following  tonsillitis.  Apolant,  in  a 
patient  who  recovered  from  an  attack  of  appendicitis,  thought  he 
observed  a  causal  relation  between  a  preceding  tonsillitis  and  the 
attack  of  appendicitis.     Kretz  records  two  cases  of  appendicitis,  in 


76  Appendicitis 

the  first  of  which,  in  a  young  woman,  he  obtained  streptococci  from 
both  the  appendix  and  the  tonsils;  and  in  the  second  case,  in  a  young 
man,  he  recovered  streptococci  from  the  appendix,  and  influenza 
bacilli  as  well  as  streptococci  from  the  tonsils.  Weber  has  reported 
three  cases  of  appendicitis  following  angina;  and,  in  reviewing  the 
literature,  refers  to  similar  cases  recorded  by  Brazil,  Routier,  Simonin, 
Schnitzler,  and  Rudolph,  as  well  as  by  the  other  authors  mentioned 
above.  Mayer  has  recently  recorded  a  case  of  gangrenous  pharyn- 
gitis followed  by  appendicitis. 

Some  two  years  since  the  following  case  came  under  my 
observation : 

A  girl,  aged  seven  years,  had  been  taken  sick  ten  days  previously  with  sore 
throat,  difficulty  in  swallowing,  high  fever  and  so  forth.  The  attending  physi- 
cian the  day  following  the  onset  found  patches  upon  the  throat  which,  when 
examined  bacteriologically,  showed  the  diphtheria  bacillus.  The  patient 
recovered  under  the  administration  of  antitoxin,  when  at  the  end  of  a  week 
she  was  seized  with  acute  abdominal  pain  followed  by  abscess  formation  in 
the  appendiceal  region.  Three  days  later  I  saw  the  girl  in  consultation  and 
advised  simple  evacuation  of  the  collection,  which  presented  well  toward  the 
crest  of  the  ilium.  This  was  done  under  ether  anaesthesia,  from  which  the 
patient  reacted  very  satisfactorily.  At  the  end  of  the  second  day  the  patient 
died  suddenly,  death  being  attributed  to  diphtheritic  paralysis  of  the  heart. 

Rheumatism  has  been  assumed  by  some  to  be  a  causative 
factor  in  the  production  of  appendicitis  and  several  cases  of  rheumatic 
appendicitis  have  been  reported.  As  the  evidence  at  hand  seems 
to  indicate  that  rheumatism  is  either  an  infection  or  an  intoxication, 
it  is  not  unlikely  that  the  organism  provocative  of  the  articular 
alterations  may  inaugurate  disease  of  the  appendix.  The  proba- 
bility of  this  is  further  enhanced  because  of  the  predilection  of  the 
rheumatic  infective  agent  for  certain  adenoid  tissues,  such  as  those 
of  the  tonsils,  and  by  analogy  also  the  tissues  of  the  appendix. 
Personally,  however,  I  have  never  encountered  a  case  in  which  rheu- 
matism and  appendicitis  were  associated. 

Goodhart  mentions  a  frequent  stomach-ache  as  a  "feature  of  the 
rheumatic  child."  Sutherland  notes  the  association  between  appen- 
dicitis and  rheumatic  symptoms  in  two  cases  of  boys  of  eight  and 
nine  years,  respectively.  Sir  James  Grant  reports  a  case  of  appen- 
dicitis following  persistent  pains  in  the  feet  and  followed  by  acute 


Clinical  Etiology  '  77 

rheumatic  fever.  Haig  reports  cases  of  rheumatic  typhlitis,  which  he 
apparently  considers  the  same  as  retrocedent  gout.  He  found  that 
salicylates  had  a  marvelous  effect  in  allaying  the  pain.  Yeo  and 
Brazil  each  report  a  similar  case  of  appendicitis  associated  with 
rheumatism.  Sutherland  considers  the  association  of  the  two 
diseases  commoner  in  children  than  adults.  Besides  the  cases 
referred  to  above,  he  here  adds  6  more,  in  children  from  six  to  twelve 
years,  who  had  attacks  of  appendicitis  accompanied  by  acute 
rheumatic  fever,  endocarditis,  or  tonsillitis.  Other  cases  of  like 
nature  are  those  reported  by  Poynton,  and  by  Finney  and  Ham- 
burger. The  latter  authors  refer  also  to  a  case  reported  by  Pribram. 
Adrian,  Goluboff,  and  Gagnieres  have  contributed  further  articles 
to  the  literature  of  appendicitis  considered  as  a  local  manifestation 
of  a  general  disease. 

Various  Infectious  Diseases. — Jalaguier  saw  appendicitis 
follow  measles,  chicken-pox,  scarlet  fever,  and  mumps,  as  well  as 
typhoid  fever  and  acute  articular  rheumatism.  Tripier  and  Paviot 
observed  perforative  appendicitis  following,  and  in  their  opinion 
caused  by,  an  infected  bullet  wound  of  the  forearm. 

Purpura  haemorrhagica  has  been  held  responsible  for  the  onset 
of  symptoms  of  appendicitis,  in  a  case  recorded  by  N.  Jacobson. 
He  cites  other  cases  of  purpura  haemorrhagica  with  intestinal  haemor- 
rhage. Box  and  Wallace  observed  a  case  mistaken  for  typhoid 
fever,  because  of  the  intestinal  haemorrhage,  but  found  at  autopsy 
to  be  one  of  suppurative  appendicitis,  with  no  lesions  in  other  parts 
of  the  intestinal  tract.     There  was  no  evidence  here  of  purpura. 

The  most  important  predisposing  cause  of  appendicitis  is  the 
fact  that  the  appendix  has  already  been  the  seat  of  one  or  more 
attacks  of  the  same  affection.  The  reasons  for  this  will  be  dis- 
cussed more  in  detail  in  the  section  on  the  pathogenesis.  Clinically, 
the  fact  is  well  established  that  those  who  have  had  one  attack  of 
appendicitis  are  most  likely  to  suffer  from  others.  Among  my  own 
cases,  a  history  of  a  previous  attack  could  be  obtained  in  nearly 
85  per  cent. 

Of  the  exciting  causes  of  appendicitis,  from  the  clinical 
point  of  view,  disturbances  of  digestion  are  the  most  important. 
Such  is  the  pre-eminence  of  these  in  the  aetiology  of  appendicitis, 
and  with  such  constancy  have  they  been  observed,  that  it  is  un- 


yS  '  Appendicitis 

hesitatingly  asserted  that  appropriate  inquiry  will  elicit  a  history 
of  such  disturbances  in  almost  all  cases.  The  alterations  induced 
by  or  causing  the  acute  indigestion  may  spread  to  the  appendix, 
and,  causing  swelling  of  the  mucous  membrane,  may  prevent 
drainage  and  lead  to  appendicitis.  When  the  digestion  is  faulty 
the  bacterial  flora  of  the  intestine  may  be  much  increased  and 
pathogenic  organisms  be  present  in  abundance.  The  catarrhal 
conditions  which  are  then  engendered  also  ofifer  less  opposition  to 
bacterial  invasion  than  does  the  healthy  mucous  membrane.  In 
this  connection  however  it  must  be  remembered  that  indigestion  is 
quite  as  often  the  result  of  disease  of  the  appendix  as  the  reverse. 
That  exposure  to  inclement  weather  and  to  other  deleterious 
influences  acts  as  an  exciting  cause  of  appendicitis  cannot  be  doubted. 
The  connection  between  the  exposure  and  the  development  of  the 
appendicitis  is  most  clear  and  direct,  and  must  be  accepted  as 
clinically  important. 

Traumatism  had  been  given  by  many  authors  as  an  exciting 
cause  of  appendicitis  and  many  of  the  cases  apparently  being  authen- 
tic. Sonnenberg  and  Deaver  have  collected  many  of  the  instances. 
In  a  careful  search  of  histories  of  500  cases  of  acute  appendicitis 
there  was  no  evidence  of  traumatism  as  a  causative  factor  and  in  my 
whole  experience  I  have  never  encountered  an  undoubted  instance 
of  appendicitis  caused  by  trauma. 

Of  other  diseases  that  act  as  exciting  causes  of  appendicitis  may 
be  mentioned  typhoid  fever,  dysentery,  tuberculosis,  actinomycosis, 
etc.  The  ordinary  lesions  of  the  appendix  in  typhoid  fever  have 
already  received  attention.  The  ulceration  may  progress,  and  may 
lead,  with  or  without  perforation,  to  appendicular  peritonitis,  and, 
as  a  consequence,  to  the  ordinary  manifestations  of  appendicitis 
with  peritonitis.  Such  are  the  diagnostic  difficulties  presented  by 
some  of  these  cases  that  the  question  of  the  presence  of  typhoid  fever 
or  appendicitis,  or  of  one  as  a  complication  of  the  other,  cannot  be 
decided  without  recourse  to  operation. 

Dysentery  rarely  leads  directly  to  the  development  of  acute 
appendicitis,  but  the  possibility  of  its  occurrence  should  be  borne 
in  mind.  The  relation  of  tuberculosis  and  actinomycosis  to  the 
development  of  appendicitis  will  be  discussed  in  the  section  on 
Pathology. 


Clinical  ^Etiology  79 

Intestinal  parasites  have  been  held  responsible  for  attacks  of 
appendicitis  by  Metchnikoff,  who  mentions  four  cases  in  which 
recurrent  attacks  of  appendicitis  ceased  after  lumbricoids  had  been 
expelled  by  the  action  of  vermifuges.  He  refers  to  Becquerel,  who, 
over  sixty  years  ago,  found  at  autopsy  an  appendix  perforated  by 
lumbricoids.  Other  cases,  Metchnikoff  says,  have  been  reported 
by  Natale,  Brun,  Guinard,  and  Girard.  Bloodgood  reports  a  case 
of  appendiceal  abscess  from  perforation  by  round  worms,  the  abscess 
being  localized  between  the  layers  of  the  ileac  mesentery;  while 
Rammstadt  observed  a  case  of  appendicitis  caused  by  the  presence 
of  the  oxyuris. 


PATHOLOGY. 

A  just  conception  of  the  nature  of  appendicitis,  as  of  other  dis- 
eases, is,  of  course,  not  possible  from  a  study  of  the  pathological 
characteristics  of  its  terminal  stages  alone;  to  be  reliably  informed 
of  its  pathogenesis  especial  attention  must  be  directed  also  to  the 
alterations  that  occur  in  the  very  inception  of  the  disease.  It  is  to 
the  infrequency  of  death  in  the  early  stages  of  appendicitis,  to  its 
non-occurrence  in  mild  cases,  and  the  consequent  lack  of  opportunity 
for  the  study  of  the  early  and  mild  pathological  conditions,  that  the 
older  and  erroneous  views  with  regard  to  the  affection  then  recog- 
nized as  typhlitis,  perityphlitis,  etc.,  may  be  attributed.  It  is  only 
at  a  comparatively  recent  date  that  the  true  nature  of  inflammations 
of  the  right  iliac  fossa  has  been  determined,  and  this  largely  through 
the  investigation  of  diseased  appendices  removed  by  early  operation. 

The  classification  of  appendicitis  has  long  been  a  moot  subject. 
Naturally  it  must  vary  with  the  basis  of  classification  adopted — 
aetiological,  anatomical,  or  clinical.  ^Etiologically  appendicitis  is 
an  infectious  process — the  consequence  of  bacterial  infection  of 
the  appendix.  One  may  well  doubt  that  a  case  of  appendicitis  ever 
occurs  independently  of  the  operations  of  bacteria;  even  in  cases 
following  trauma,  animal  parasitic  invasion  of  the  appendix,  inter- 
ference with  the  blood  supply  (by  means  of  twists,  angulations,  or 
adhesions),  etc.,  bacteria  are  the  active  agents  in  causing  the  inflam- 
matory lesions.  An  amplification  of  the  aetiological  classification 
suggests  such  terms  as  bacterium  coli  infection,  streptococcic  infec- 
tion, staphylococcic  infection,  pneumococcic  infection  of  the  appen- 
dix, etc.  Doubtless  in  some  cases  these  different  infective  agents  give 
rise  to  varying  clinical  manifestations,  but  at  present  these  are 
scarcely  susceptible  of  clinical  differentiation.  It  is  likely,  however, 
that  the  future  may  enable  us  to  make  such  differentiation — ^by  means 
of  certain  at  present  ill-observed  clinical  manifestations,  by  serum 
reactions  and  other  laboratory  methods,  etc.  For  the  present, 
however,  all  that  can  be  said  is  that  aetiologically  appendicitis  is  an 
infectious  process. 

80 


Pathology  8i 

Anatomically,  as  well  as  clinically,  two  varieties  of  inflammation 
of  the  vermiform  appendix  may  be  recognized — an  acute  and  a 
chronic  appendicitis.  Like  inflammation  elsewhere  in  the  body, 
the  inflammatory  manifestations  in  the  appendix  may  commence 
acutely  or  chronically.  If  the  former  be  the  case,  the  acute  manifes- 
tations may  subside  after  a  greater  or  less  interval  of  time,  and  the 
pathological  alterations  may  persist  as  a  chronic  inflammation. 
Thus,  chronic  inflammation  may  be  the  residual  manifestation  of 
a  previous  acute  inflammation,  or  the  condition  may  begin  as  a 
chronic  inflammation.  Of  the  acute  and  chronic  forms  of  appen- 
dicitis, several  varieties  may  be  distinguished,  and  for  purposes  of 
anatomical  and  histological  study  it  is  deemed  advisable  to  adopt 
some  rational  classification.  The  following  pathologico-anatomical 
classification,  based  upon  the  results  of  this  investigation,  but  which 
does  not  differ  essentially  from  several  that  have  already  been 
proposed,  is  suggested: 

A  cute  A  ppendicitis : 

1.  Catarrhal. 

2.  Interstitial. 

3.  Ulcerative, 

{a)  Non-perforative. 
{h)  Perforative. 

4.  Gangrenous. 
Chronic  Appendicitis: 

1.  Catarrhal. 

2.  Interstitial. 

3.  Obliterating. 

This  classification,  which  is  anatomically  well  founded,  as  it 
indicates  the  nature  of  the  lesions  of  the  appendix,  is  not  in  contra- 
vention of  the  clinical  course  of  the  disease.  It  must  be  candidly 
admitted,  however,  that  we  are  not  always  able  to  distinguish  clin- 
ically the  different  pathologico-anatomical  varieties  of  appendicitis. 
In  other  words,  the  different  pathologico-anatomical  varieties  of  the 
affection  may  present  analogous  clinical  manifestations.  Again, 
the  severity  of  the  clinical  manifestations  of  an  individual  attack  of 
appendicitis  frequently  bears  no  relation  to  the  seriousness  of  the 
lesions  of  the  appendix,  nor  is  the  number  of  attacks  always  a  trust- 
worthy index  of  the  condition  of  the  appendix.  And,  further,  it 
6 


82  Appendicitis 

may  be  said  that  often  the  different  varieties  of  both  acute  and 
chronic  appendicitis  are  but  stages  of  a  single  pathological  process. 
An  inflammation  of  the  appendix,  originating  as  a  catarrh,  may,  in 
a  given  instance,  progress  to  the  interstitial  variety.  This  in  turn 
may  be  succeeded  by  ulceration  which,  depending  upon  a  variety  of 
circumstances,  may  or  may  not  lead  to  perforation  of  the  organ. 
Gangrenous  appendicitis  may  also  follow  in  such  a  train  of  events, 
though  it  not  infrequently  arises  in  a  totally  different  manner. 
Similarly,  chronic  interstitial  appendicitis  may  follow  that  process 
which  began  as  a  chronic  catarrh,  and  not  the  least  interesting,  if 
not  the  most  common,  form  of  this  chronic  inflammation  of  the  ap- 
pendix is  the  obliterating  variety.  Again,  an  appendix  that  for  a 
longer  or  shorter  period  of  time  has  been  the  seat  of  chronic  inflam- 
mation may  suddenly  suffer  an  acute  exacerbation,  and  may  present 
the  most  intense  degrees  of  acute  interstitial  inflammation,  with 
suppuration,  ulceration,  or  gangrene,  and  well-marked  and  fatal 
peritonitis.  On  the  other  hand,  a  severe  attack  of  appendicitis  may 
be  partially  recovered  from,  and  may  be  succeeded  by  several 
much  milder  attacks.  Indeed,  an  acute  exacerbation  of  the  lesions 
of  a  chronically  inflamed  appendix  is  one  of  the  most  likely  of  events. 
The  majority  of  cases  of  chronic  appendicitis  are  those  in  which  the 
appendix  has  been  the  seat  not  only  of  a  chronic  inflammation,  but 
also  of  recurring  attacks  of  more  or  less  acuteness — cases  designated 
clinically  as  recurring  or  relapsing  appendicitis.  In  addition,  the 
inflammatory  phenomena  in  different  appendices  vary  with  respect 
to  the  situation  and  extent  of  the  lesions  and  the  rapidity  of  their 
progress;  and  these  are  not  uninfluenced  by  the  possibly  persisting 
consequences  of  previous  inflammation.  Furthermore,  the  most 
diverse  peritoneal  lesions  may  be  associated  with  different  cases  of 
the  same  variety  of  appendicitis. 

The  foregoing  classification,  based,  as  it  is,  upon  the  nature  and 
character  of  the  lesions  occurring  in  the  several  varieties  of  appen- 
dicitis, seems  more  appropriate  than  those  which  comprise  such 
terms  as  "simple,"  "mild,"  "perforating,"  "infective,"  etc.  "Sim- 
ple" and  "mild,"  as  a  rule,  are  used  merely  to  indicate  the  severity 
of  the  clinical  manifestations,  and,  as  already  stated,  this  is  often  no 
index  to  the  seriousness  of  the  lesions  of  the  appendix,  although,  of 
course,  "mfld"  lesions  do  occur.     "Perforative"  merely  indicates 


Pathology  83 

an  accident  that  may  or  may  not  happen  in  the  course  of  ulcerative 
and  gangrenous  appendicitis.  The  reservation  of  the  term  "infec- 
tive" to  designate  certain  cases  only  of  appendicitis  is  inappropriate; 
for,  as  has  been  stated  and  as  will  be  seen  later,  all  cases  of  appen- 
dicitis must  be  attributed  to  the  pathogenetic  activities  of  bacteria. 
The  pathology  of  inflammation  of  the  vermiform  appendix 
will  be  discussed  as  follows: 

1.  The  Lesions  of  the  Appendix. 

2.  The  Peritonitis  and  its  Consequences. 

3.  The  Bacteriology. 

4.  The  Pathogenesis. 

THE  LESIONS  OF  THE  APPENDIX. 

ACUTE  APPENDICITIS. 

ACUTE  CATARRHAL  APPENDICITIS. 

By  acute  catarrhal  appendicitis  is  understood  that  variety  of 
acute  inflammation  of  the  appendix  in  which  the  pathological 
alterations  are  wholly  or  almost  wholly  confined  to  the  mucous 
membrane,  the  other  coats  of  the  organ  presenting  but  little  or  no 
deviation  from  the  normal.  In  this  connection  the  term  catarrhal 
is  employed  strictly  within  its  pathological  significance.  Implying, 
as  it  does,  a  superficial  inflammation  limited  to  the  mucous  mem- 
brane, it  is  certainly  incorrect  to  apply -it,  as  has  been  done,  to 
inflammatory  conditions  of  the  appendix  in  which  the  lesions 
involve  the  deeper  layers  of  the  wall  of  the  organ. 

That  this  variety  of  appendicitis  does  occur  there  can  be  no 
question.  It  is  not  true,  as  has  been  held  by  Talamon  and  others, 
that  in  every  case  of  inflammation  of  the  appendix  all  the  coats 

Note. — The  percentages  in  this  article  are  derived  from  Dr.  A.  O.  J.  Kelly's 
original  work  for  the  second  and  third  editions,  and  we  have  found  that  what  he 
there  stated  is  still  true,  and  though  a  continued  systematic  microscopic  examination 
of  all  appendices  removed  by  Dr.  Deaver  has  been  made  (from  January  8,  1906 — 
appendix  No.  3097)  to  the  present  date  (September  i,  1912 — appendix  No.  8718), 
yet  our  conviction  is  that  a  further  elaboration  of  a  greater  number  of  cases  would  not 
have  materially  altered  the  percentages.  Dr.  Kelly's  original  deductions  were  drawn 
from  the  most  careful  study  of  577  cases.  In  this  volume,  in  an  effort  to  save  space, 
only  the  percentages  will  be  given  and  the  reader  is  referred  to  the  Third  Edition  for 
the  more  complete  statistics. 


84  Appendicitis 

are  involved,  or  that,  at  least,  the  inflammatory  alterations  extend 
to  and  implicate  the  muscular  coats.  Nor  can  I  agree  with  Kelynack 
and  others  who  consider  the  term  catarrhal  most  open  to  objection 
because  of  its  suggesting  a  superficial  inflammation — they  thereby 
implying  that  such  a  condition  does  not  occur  in  the  appendix. 

Acute  catarrhal  appendicitis  is  probably  not  uncommon.  It 
doubtless  often  gives  rise  to  but  few  clinical  manifestations,  and, 
most  likely,  under  some  circumstances  to  none  at  all,  as,  for  instance, 
if  the  lumen  of  the  organ  be  of  good  calibre.  This  opinion  is 
borne  out  by  the  many  instances  of  catarrhal  inflammation  of  the 
appendix  disclosed  by  systematic  examination  of  a  large  number 
of  appendices  removed  postmortem  from  those  who  during  life 
presented  no  clinical  manifestations  of  such  disease.  In  many 
of  these  cases  the  lesions  are  strictly  confined  to  the  mucous  mem- 
brane. That  this  variety  of  appendicitis,  however,  is  infrequently 
met  at  operation  is  indicated  by  the  fact  that  of  239  cases  of  acute 
appendicitis  that  were  investigated,  but  9  were  of  the  catarrhal 
variety.  It  is  quite  likely,  nevertheless,  that  if  many  of  the  appen- 
dices which  when  deranged  give  rise  to  very  mild  clinical  symptoms 
were  examined  microscopically,  they  would  reveal  evidences  of 
catarrhal  inflammation.  It  is  likely,  also,  that  this  variety  of 
appendicitis  constitutes  the  early  stage  of  many  cases  of  the  more 
severe  varieties  of  acute  inflammation,  and  it  is  doubtless  commonly 
the  starting-point  of  many  of  the  chronic  cases. 

Macroscopy. — ^In  this  variety  of  appendicitis,  to  the  naked  eye 
the  general  configuration  and  external  appearances  of  the  organ 
are  not  appreciably  altered,  although  it  may  feel  a  little  stiffer  or 
firmer  to  the  touch.  The  mucous  membrane  is  swollen,  hyperaemic, 
and  cedematous.  The  lumen  of  the  organ  may  be  partially  or 
completely  occluded  at  one  point  or  at  several  points,  and  this  is 
the  more  likely  to  be  the  case,  the  narrower  the  lumen  prior  to  the 
attack  of  inflammation  and  the  more  intense  the  inflammation. 
The  mucous  membrane  is  covered  with  a  secretion  that  partly  or 
completely  fills  the  lumen  of  the  organ  if  it  be  patulous.  This 
secretion  is  variable  in  amount  and  character.  It  may  be  abundant 
or  meagre,  depending  to  a  considerable  extent  upon  the  intensity 
of  the  inflammation  (and  whether  or  not  the  catarrhal  alterations 
are   associated   with   more   widespread   lesions).     In   character   it 


Pathology  85 

may  be  clear  and  mucous,  turbid,  grayish  or  yellowish- green,  or 
brownish  and  purulent;  or  sanguinolent;  or  a  combination  of  any 
of  these.  The  contents  of  the  appendix  vary,  depending  upon 
whether  they  consist  solely  of  such  secretion,  or  of  such  secretion 
combined  with  more  or  less  faecal  matter.  They  may  be  fluid  or 
semi-fluid,  or  they  may  approach  the  consistency  of  inspissated 
faecal  matter.  In  this  variety  of  appendicitis  I  have  not  encountered 
any  true  appendicular  calculi.  The  odor  of  the  contents  is  also 
variable.  It  is  commonly  distinctly  faecal  in  character,  with  different 
degrees  of  malodorousness.  Occasionally  the  lymphoid  follicles 
appear  enlarged.  The  crypts  of  Lieberkiihn  can  usually  be  detected, 
being  distinctly  distended,  commonly  with  a  grayish  or  a  grayish- 
yellow  secretion.  If  the  inflammation  be  rather  intense  and,  as  is 
the  rule,  the  lesions  extend  beyond  the  mucosa,  the  secretion  is 
likely  to  be  distinctly  purulent;  hence  the  designation,  purulent 
catarrhal  appendicitis.  Under  such  circumstances  slight  superficial 
erosion  and  desquamation  of  the  epithelium  of  the  mucous  mem- 
brane may  supervene,  and  if  the  inflammation  be  still  more  intense, 
rupture  of  minute  vessels  in  the  lowermost  layers  of  the  mucosa 
may  occur.  The  haemorrhagic  foci  that  thus  ensue  have  lead  to 
the  designation  hcemorrhagic  catarrhal  appendicitis.  These  various 
lesions  may  extend  uniformly  throughout  the  length  of  the  appendix, 
or  they  may  be  relatively  intense  in  one  portion  and  comparatively 
inconspicuous  in  others.  Indeed,  certain  regions  may  be  entirely 
unaffected. 

Microscopy. — Upon  microscopical  examination  of  such  appen- 
dices the  crypts  of  Lieberkiihn  are  found  distended  to  a  variable 
degree.  Usually  the  contents  are  of  the  well-known  mucous 
nature;  occasionally,  however,  they  are  muco-purulent,  purulent, 
or  haemorrhagic — in  the  event  of  which  the  lesions  usually  extend 
beyond  the  mucosa.  The  individual  epithelial  cells  of  these  crypts, 
as  well  as  those  of  the  surface  epithelium,  are  swollen,  distorted, 
and  occupied  by  a  clear,  translucent,  spheroid,  or  ovoid  droplet 
which,  situated  toward  the  free  extremity  of  the  cell,  displaces  the 
cell  protoplasm  and  the  nucleus  downward  or  somewhat  to  one  side. 
This  droplet  reveals  the  characteristics  of  mucin  generally,  and  is 
commonly  elaborated  without  destruction  of  the  cell  body.  After 
the   discharge   of   this   droplet  the  cells  reveal  the  characteristic 


86  Appendicitis 

goblet  appearance,  and  subsequently  they  may  assume  their  normal 
configuration  and  appearance.  Some  emigrated  leucocytes  are 
usually  visible  between  the  epithelial  cells,  and  the  entire  mucosa 
is  the  seat  of  more  or  less  serous  infiltration.  Besides  these  altera- 
tions and  some  congestion  of  the  vessels  of  the  mucosa  and  sub- 
mucosa  the  mild  forms  of  this  variety  of  inflammation  of  the  appen- 
dix may  present  no  noteworthy  pathological  features.  If,  however, 
the  inflammation  be  more  intense,  in  addition  to  the  foregoing 
changes  there  are  noticeable  a  more  marked  congestion  of  the 
vessels  of  the  mucosa  and  submucosa,  a  greater  degree  of  serous 
infiltration,  a  more  marked  infiltration  of  the  retiform  tissue  of  the 
mucous  membrane  with  emigrated  leucocytes,  some  cellular 
proliferation  and  desquamation  of  the  epithelial  cells  of  the  crypts 
of  Lieberkiihn  and  of  those  lining  the  lumen  of  the  appendix. 
The  difference  between  this  and  acute  interstitial  appendicitis  is 
one  of  degree  only,  and  all  gradations  are  encountered.  In  some 
of  the  severer  cases  the  cellular  exudate  becomes  more  excessive, 
and  gives  rise  to  marked  swelling  of  the  mucous  membrane  and  to 
pressure  upon  the  crypts  of  Lieberkiihn.  Partly  because  of  this, 
and  also  because  of  the  desquamation  of  their  epithelial  lining, 
some  of  these  crypts  become  obliterated.  Under  such  circumstances 
the  cellular  exudate  reaches  the  surface  of  the  lumen,  and  being 
cast  off,  commingled  with  desquamated  epithelial  cells,  excessive 
mucus,  and  granular  debris,  constitutes  the  microscopical  evidence 
of  what  has  been  termed  purulent  catarrhal  appendicitis.  The 
contents  of  the  lumen  are  composed  of  similar  matter.  The 
desquamation  of  the  epithelial  cells  may  occur  slowly  or  rapidly, 
and  the  cells  desquamated  may  be  in  a  good  state  of  preservation 
or  they  may  be  already  partly  or  completely  necrotic,  or  the  seat 
of  serous  or  mucous  infiltration.  If  the  inflammation  be  still  more 
intense,  the  alterations  already  described  become  more  marked, 
and  there  may  occur  some  diapedesis  of  erythrocytes.  Indeed, 
in  a  small  number  of  cases  minute  hsemorrhagic  foci  may  be  detected 
— hcemorrhagic  catarrhal  appendicitis.  Noeggerath  asserts  on  experi- 
mental grounds  that  such  minute  hsemorrhagic  foci  are  usually 
traumatic,  and  Letulle  supports  this  statement  and  asserts  that 
such  hsemorrhages  are  often  demonstrable  in  the  entire  absence 
of  any  signs  of  inflammation  of  the  appendix.     In  view  of  these 


Pathology  87 

investigations  it  would  seem  probable  that  at  least  some  of  the 
haemorrhages  of  this  nature  have  been  caused  by  the  trauma  incident 
to  the  removal  of  the  appendix.  In  all  cases  of  catarrhal  appendi- 
citis, excluding  possibly  the  very  mildest  forms,  there  is  some  swell- 
ing, congestion,  and  serous  infiltration  of  the  lymph  nodules. 

The  further  course  of  such  catarrhal  appendicitis  is  one  of 
three :  In  a  very  few  instances  it  is  possible  that,  if  the  lesions  be 
very  slight,  a  complete  restoration  of  the  mucous  membrane  to 
its  former  condition  may  take  place.  The  contents  of  the  appendix 
are  discharged  into  the  cascum,  the  congestion  and  swelling  of  the 
mucous  membrane  subside,  the  leucocytic  infiltration  and  the 
cellular  exudate  are  absorbed,  and  desquamated  and  eroded 
epithelial  cells  are  replaced  by  newly  formed  cells.  The  likelihood 
of  such  restitutio  ad  integrum  is  influenced  by  the  cause  of  the 
inflammation,  the  free  and  thorough  drainage  of  the  organ,  and 
the  character  and  virulence  of  the  micro-organisms  present.  Anal- 
ogy and  some  facts  warrant  us  in  supposing  that  such  mild  catarrhal 
appendicitis  is  more  common  than  is  generally  thought,  that  clinical 
manifestations  are  often  slight  or  entirely  absent,  and  that  in  some 
such  instances  the  appendices  return  to  their  previously  normal 
condition.  However,  in  the  majority  of  cases  in  which  the  lesions 
are  sufliciently  intense  to  give  rise  to  clinical  manifestations,  and 
in  all  cases  in  which  the  previously  detailed  pathological  alterations 
are  at  all  marked,  the  return  of  the  appendix  to  its  normal  condition 
is  not  possible.  The  acute  manifestations  either  partly  subside 
and  become  chronic,  or  they  become  more  intense,  more  generalized, 
and  lead  to  some  of  the  severer  forms  of  appendicitis.  This  latter 
is  a  very  likely  event,  not  only  because  of  the  natural  tendency 
of  the  disease,  but  also  because  of  the  liberal  lymphatic  supply 
of  the  appendix,  whereby  the  noxious  agents  provocative  of  the 
lesions  of  the  mucous  membrane  readily  gain  access  to,  and  implicate 
the  deeper  layers  of,  the  wall  of  the  organ. 

ACUTE  INTERSTITIAL  APPENDICITIS. 

By  acute  interstitial  appendicitis  is  understood  that  variety 
of  acute  inflammation  of  the  appendix  in  which  the  pathological 
alterations   extend  throughout  and  involve   all  the  coats   of  the 


88  Appendicitis 

organ.  An  inflammation  of  the  appendix  may  implicate  all  the 
coats  of  the  organ  from  the  outset,  but,  as  already  stated,  it  is  not 
unlikely  that  catarrhal  alterations  inaugurate  the  process  in  a  con- 
siderable number  of  cases.  The  extensive  lymphatic  supply  of 
the  organ  furnishes  a  ready  means  for  the  rapid  dispersion  of  the 
agents  causing  the  inflammation,  thus  engendering  the  generalization 
of  the  process.  That  this  form  of  appendicitis  is  more  common 
than  the  catarrhal  variety,  or  at  least  gives  rise  to  clinical  mani- 
festations more  frequently  is  indicated  by  the  fact  that  of  239  cases 
of  acute  appendicitis  examined,  38  were  of  the  interstitial  variety. 
In  this  form  the  pathological  alterations  are  commonly  more 
intense  in  one  coat  than  in  others,  and  they  vary  also  in  different 
regions  of  the  same  coat. 

Macroscopy. — To  the  naked  eye  the  appendix  appears  swollen, 
cedematous,  and  reddened;  and  injection  of  many  of  the  vessels 
beneath  the  peritoneal  covering  can  commonly  be  distinctly  de- 
tected. If  the  inflammation  be  of  minor  grade,  the  organ  is 
quite  firm  to  the  touch;  but  if  it  be  either  moderate  or  intense,  the 
appendix  often  seems  softer  than  normal.  The  mucous  membrane 
is  swollen,  hyperaemic,  cedematous,  and  softened,  and  the  entire 
wall  of  the  organ  appears  thicker  than  normal.  The  mucous 
membrane  is  more  likely  to  reveal  minute  haemorrhages  than  in 
catarrhal  appendicitis.  Occlusion  of  the  lumen  in  one  or  more 
places  is  common.  If  it  be  patulous,  the  contents  are  muco-puru- 
lent,  purulent  or  haemorrhagic  and  they  are  more  likely  to  be  the 
last  named,  and  also  to  be  very  malodorous,  in  this  than  in  the  ca- 
tarrhal variety.  The  other  macroscopical  appearances  do  not  differ 
materially  from  those  described  in  connection  with  the  catarrhal 
variety  (with  which  it  is  usually  associated),  though  the  swelling  of 
the  lymphoid  follicles  is  more  likely  to  be  conspicuous.  Appendic- 
ular calcuh  were  found  in  6.2  per  cent,  of  the  appendices 
examined. 

Microscopy. — Upon  microscopical  examination  the  pathological 
dlterations  described  in  connection  with  the  microscopy  of  catarrhal 
appendicitis  are  evident.  They  are,  however,  commonly  more 
marked  in  degree.  The  crypts  of  Lieberkiihn  are  often  almost 
completely  obliterated,  there  is  dense  cellular  infiltration  of  the 
retiform  tissue  of  the  mucous  membrane,   and  the  latter  is  not 


Pathology  89 

infrequently  represented  by  a  dense  aggregation  of  small  round  cells 
which  extend  to  the  free  edge,  and  in  which  remnants  of  degenerated 
epithelial  cells  and  crypts  of  Lieberkiihn  are  discernible.  In  addi- 
tion, the  pathological  alterations  have  extended  to,  and  more  or  less 
extensively  involve,  the  submucous,  muscular,  and  subserous  coats. 
Throughout  the  submucous  and  muscular  coats  there  are  a  variable 
amount  of  dilatation  of  the  blood-vessels,  some  serous  infiltration, 
and  a  more  or  less  dense  collection  of  small  round  cells.  At  times 
these  small  round  cells  infiltrate  more  or  less  diffusely  one  or  all 
of  the  layers  of  the  wall  of  the  appendix,  causing  separation  of  the 
fibrillar  and  muscular  bundles  and  constituting  a  veritable  purulent 
or  phlegmonous  infiltration  or  suppuration  of  the  appendix.  On  the 
other  hand,  these  small  round  cells  may  be  congregated  into  smaller 
or  larger  masses,  forming  circumscribed  abscesses — interstitial 
abscesses — ^in  various  regions  of  the  organ.  While  the  diffuse 
infiltration  is  more  likely  to  predominate  in  the  muscular  layers,  the 
small,  circumscribed  abscesses  show  a  predilection  for  the  submucous 
and  subserous  layers.  No  definite  rules,  however,  can  be  laid 
down  for  these.  The  leucocytic  infiltration  is  especially  conspicuous 
about  the  blood-vessels,  but  evidences  of  productive  inflammatory 
alterations  are  common  elsewhere.  In  cases  of  moderate  and  more 
intense  inflammation  haemorrhagic  foci  are  relatively  common. 
At  times  these  are  small;  at  times,  however,  they  are  very  extensive, 
and  give  rise  to  more  or  less  widespread  destruction  of  tissue. 

A  conspicuous  feature  of  this,  as  well  as  of  the  more  severe 
varieties  of  appendicitis,  is  the  involvement  of  the  lymphoid  ele- 
ments. These  are  commonly  swollen  and  are  generally  the  seat  of 
serous  infiltration.  The  capillaries  and  lymph  spaces  appear  dis- 
tended— the  former  filled  with  blood  corpuscles,  the  latter  with 
lymph  corpuscles,  leucocytes,  and  sometimes  erythrocytes — and 
into  their  lumens  there  project  proliferating  endothelial  cells.  At 
times  the  latter  desquamate,  and  thus  assist  in  occluding  the  dis- 
tended spaces.  There  also  occur  an  infiltration  of  the  nodules 
with  leucocytes  and  an  active  proliferation  of  the  cells  of  the  retic- 
ulum. In  the  immediate  vicinity  of  these  lymphoid  follicles  there 
are  often  small  collections  of  lymphoid  cells;  these  should  not  be 
confounded  with  the  results  of  productive  inflammation,  which 
also  abound.     In  the  more  advanced  stages  of  the  inflammation 


90  Appendicitis 

these  lymphoid  follicles  undergo  various  retrograde  changes.  They 
commonly  become  necrotic,  the  necrosis  arising  in  one  of  two  ways: 
it  may  commence  in  or  about  the  centre  of  the  follicle,  and  more  or 
less  rapidly  involve  the  entire  nodule;  or  small  scattered  foci  of 
necrosis  may  simultaneously,  or  almost  simultaneously,  arise  in 
different  portions  of  the  follicle,  and,  finally,  either  become  confluent 
or  remain  discrete.  It  has  seemed  to  me  that  the  latter  form  of 
necrosis  is  the  more  common.  At  first  the  nuclei  of  the  lymphoid 
cells,  and  later  those  of  the  reticulum,  refuse  to  stain  well.  They 
appear  indistinct  and  blurred,  and  their  edges  become  ragged. 
Subsequently  hyperchromatosis,  chromatolysis,  or  karyorrhexis 
supervenes,  and  plasmolysis  follows  or  occurs  coincidentally. 
Finally,  the  focus  undergoes  complete  liquefaction.  Neighboring 
areas  become  similarly  affected,  and  several  adjoining  foci  may 
become  confluent  and  form  larger  ones.  The  exudated  polynuclear 
leucocytes  participate  in  the  process  and  speedily  become  liquefied. 
The  reticulum,  sometimes  at  first  homogeneous,  later  becomes 
granular  and  liquefies.  There  thus  develops  within  the  wall  of 
the  appendix,  without  of  necessity  any  solution  of  the  continuity  of 
the  mucous  membrane  or  of  the  serous  coat  developing,  a  focus  or 
several  foci  of  softening  which,  in  the  later  stages  at  least,  consist 
largely  of  purulent  msLtter— follicular  abscess.  This  commonly 
ruptures  into  the  lumen  of  the  appendix,  and  there  is  thus  produced 
a  form  of  ulcerative  appendicitis,  of  which  mention  will  be  made 
subsequently.  Haemorrhage  sometimes  occurs  into  these  foci  of 
softening,  and  around  them,  at  times,  various  deposits  of  blood 
pigment  are  discernible. 

The  pathological  anatomy  of  this,  as  well  as  of  the  ulcerative, 
form  of  appendicitis  varies  somewhat,  depending  upon  the  possibly 
persisting  consequences  of  previous  inflammation.  At  times,  as  a 
result  of  previous  acute  or  chronic  inflammation,  strictures,  angula- 
tions, or  flexures  may  have  formed,  obstructing  the  lumen  of  the 
organ.  Under  such  circumstances  the  appendix  may  be  divided 
into  two  or  more  compartments,  and  each  of  these  may  present 
pathological  alterations  different  from  the  others.  One  portion 
may  reveal  only  catarrhal  inflammation;  another,  in  addition  to 
this,  rather  marked  interstitial  inflammation;  while,  under  some 
circumstances,    another   portion   may   be   practically   unaffected. 


Pathology  91 

The  proximal  portion  is  the  most  likely  to  present  no  deviations 
from  the  normal.  The  tip,  on  the  other  hand,  is  not  infrequently 
seriously  involved,  being  distended  and  filled  with  clear  or  turbid 
fluid  or  with  pus.  The  contents  of  the  distended  portion  may  be 
purulent  from  the  commencement  of  the  inflammation,  or  there  may 
occur  a  purulent  metamorphosis  of  previously  clear  fluid.  This 
condition,  in  which  the  lumen  of  the  appendix  has  been  converted 
into  a  closed  cavity  and  is  filled  with  pus,  is  spoken  of  as  empyema 
of  the  appendix.  Under  these  circumstances  the  wall  of  the  appendix 
constitutes  the  wall  of  the  empyema  or  abscess  cavity.  The  develop- 
ment of  an  empyema  of  the  appendix  presupposes  a  stenosis  or 
complete  occlusion  of  the  lumen,  and  this  may  be  brought  about 
by  twists  or  angulations  of  the  organ,  internal  cicatrices  resulting 
from  previous  inflammation,  or  external  cicatrizing  bands  of  adhe- 
sions. The  stenosis  or  occlusion  of  the  lumen  may  occur  at  any 
point  along  the  appendix,  and  in  consequence  the  empyema  may 
involve  the  entire  organ  or  only  part  of  it.  We  thus  speak  of  a 
partial  or  complete  empyema,  as  the  case  may  be.  The  empyema 
may  develop  slowly  or  rapidly,  and  it  may  be  rather  small  or  may 
attain  a  considerable  size.  It  commonly  occurs  in  connection  with 
acute  inflammation,  but  that  it  also  develops  in  association  with 
some  cases  of  chronic  inflammation  (a  few  of  them  possibly  tuber- 
culous), and  with  acute  exacerbations  of  chronic  inflammations,  is 
well  established.  Although  in  its  initial  stages  this  condition  of 
empyema  may  be  present  without  appreciable  ulceration  of  the 
appendix— that  is,  it  may  be  associated  with  catarrhal  and  inter- 
stitial appendicitis,  with  intact  basement  membrane — from  its  very 
nature  it  forms  a  transition  stage  to  ulceration  of  the  appendix,  and 
is  commonly  found  in  connection  therewith.  If  such  an  appendix 
be  not  removed  by  operation,  there  occur  serous  and  cellular  infil- 
tration and  necrosis  of  the  wall  of  the  organ,  excessive  distention, 
perforation,  and  peritonitis.  The  final  process  is  similar  to  ulcera- 
tive appendicitis. 

It  is  not  possible  for  the  interstitial  variety  of  appendicitis  to 
eventuate  in  the  restoration  of  the  organ  to  its  previous  healthy 
condition.  If  the  pathological  alterations  are  shght  or  moderate 
in  degree,  and  if  there  are  productive  connective  tissue  changes 
rather   than  polynuclear  leucocytic  infiltration,   the   acute  mani- 


92  Appendicitis 

festations  may  subside  and  a  variety  of  chronic  appendicitis  may 
result.  It  is  much  more  Kkely,  however,  if  the  appendix  is  not 
excised  or  the  patient  does  not  die,  that  the  pathological  changes 
will  progress  to  necrosis  and  ulceration. 

ACUTE  ULCERATIVE  APPENDICITIS. 

By  acute  ulcerative  appendicitis  is  understood  that  variety  of 
acute  inflammation  of  the  appendix  in  which  there  occurs  a  lique- 
faction necrosis  of  the  inflammatory  exudate  and  of  more  or  less 
of  the  wall  of  the  organ  in  communication  with  its  lumen.  This 
is  naturally  but  an  aggravation  of  the  previously  described  forms  of 
appendicitis,  and  both  the  catarrhal  and  interstitial  varieties  may 
present  gradual  progression  to  it.  It  is  possible,  however,  for 
ulcerative  appendicitis  to  arise  without  previous  catarrh; it  maybe 
due  to  septic  infection,  typhoid  fever,  dysentery,  etc.  Two  forms 
may  be  distinguished — a  non-perforative  and  a  perforative.  One 
is  but  an  aggravation  of  the  other — perforation  being  an  accident 
that  may  or  may  not  occur  in  the  course  of  the  affection.  That 
this  variety  of  appendicitis  is  relatively  common  is  indicated  by  the 
fact  that  of  239  cases  of  acute  appendicitis  examined,  142  were  of 
the  ulcerative  variety — 68  being  non-perforative  and  74  perforative. 

Macroscopy. — ^To  the  unaided  eye  the  appendix  is  swollen, 
oedematous,  excessively  congested,  and  may  seem  a  little  firmer 
to  the  touch  than  normal,  in  consequence  of  the  tension  of  the 
peritoneal  covering.  In  the  event,  however,  of  perforation,  or  of 
perforation  being  imminent,  the  area  of  such  impending  or  actual 
perforation  can  readily  be  distinguished  by  its  being  softer  than  the 
surrounding  tissue.  The  swelling  and  oedema  vary  in  different 
portions.  Usually,  they  are  very  irregularly  distributed,  being  more 
marked  in  one  region  than  in  another.  In  places  the  seat  of  serious 
disease  the  appendix  may  be  as  thick  as  a  finger  or  thicker,  whereas 
other  portions  may  be  not  thicker  than  a  lead-pencil  and  almost 
normal  in  appearance.  Certain  regions  may  present  merely  dila- 
tation of  the  blood-vessels,  the  larger  ones  being  distinctly  distended, 
while  those  ordinarily  invisible  to  the  unaided  eye  are  readily  per- 
ceptible. In  other  portions  there  may  be  a  diffuse  redness,  varying 
in  shade  from  an  intense  bright  redness  to  a  deep  reddish-blue  or 


Pathology  93 

purplish  color.  If  perforation  be  imminent,  the  area  involved  is 
usually  of  a  brownish-green  or  blackish-green  color,  and  is  softer 
and  more  prominent  than  the  adjoining  region.  It  is  closely  sur- 
rounded by  an  area  of  intense  bright  redness,  and  is  usually  covered 
by  some  discolored  exudate.  There  may  be  only  one  of  these  spots 
of  impending  perforation  or  there  may  be  several  of  them,  and  they 
may  be  situated  anywhere  along  the  course  of  the  appendix.  Such 
spots  are  most  frequently  found  opposite  the  attachment  of  the  meso- 
appendix.  Not  uncommonly,  however,  they  are  near  the  attachment 
of  the  meso-appendix,  and  sometimes  they  are  encountered  between 
the  two  layers  of  this  structure.  Several  of  these  may  apparently 
coalesce  to  form  larger  areas.  Under  such  circumstances  perfora- 
tion of  the  wall  of  the  appendix  is  most  likely  to  ensue.  The  per- 
foration may  be  exceedingly  small — scarcely  perceptible;  or  it  may 
be  large  enough  to  admit  a  straw  or  a  goose-quill;  or,  exceptionally, 
it  may  be  upward  of  a  centimetre  in  extent.  Perforations  more  than 
a  centimetre  in  size  are  very  uncommon,  unless  as  a  result  of  circular 
amputation  or  of  widespread  gangrene  of  the  organ.  There  may  be 
only  one  perforation  or  there  may  be  several,  varying  in  size  and  sit- 
uation. They  may  be  close  together  or  quite  removed  from  one 
another.  Although,  as  a  rule,  the  perforation  occurs  in  the  centre 
of  the  previously  mentioned  spot  of  discoloration,  such  spots  may 
individually  reveal  several  perforations.  The  perforation  is  usually 
round,  but  it  may  be  ovoid,  elongated,  or  without  definite  outline. 
If  irregular,  it  may  course  in  the  direction  of  the  long  or  transverse 
axis  of  the  organ  or  diagonally.     The  edges  are  usually  very  ragged. 

Perforation  of  the  appendix  is  considered  to  have  occurred  when 
communication  has  been  established  between  the  exterior  of  the 
organ  and  its  lumen.  In  contradistinction  to  this,  it  not  infrequently 
happens  that  a  circumscribed  abscess  in  the  wall  of  the  appendix 
ruptures  externally — that  is,  through  the  serous  coat — ^without  a 
communication  being  established  with  the  lumen.  In  the  event  of 
true  perforation,  conditions  are  favorable  for  the  escape  of  faecal 
matter  from  the  lumen  of  the  appendix  into  the  peritoneal  cavity; 
in  the  other  variety  of  perforation,  or  rupture  of  a  portion  of  the  wall, 
such  an  accident  does  not  occur. 

The  contents  of  the  lumen  in  ulcerative  appendicitis  vary  but 
sHghtly;  they  may  be  muco-purulent,  though  they  are  commonly 


94  Appendicitis 

distinctly  purulent,  with  more  or  less  admixture  of  faecal  matter, 
and  very  malodorous.  On  the  other  hand,  if  perforation  has  oc- 
curred, the  lumen  may  be  practically  empty.  The  wall  of  the  appen- 
dix is  thickened,  especially  at  the  seat  of  most  manifest  disease.  On 
the  inner  aspect  marked  alterations  of  the  lining  membrane  and  a 
variable  number  of  ulcers  are  seen.  That  portion  of  the  mucous 
membrane  which  is  not  ulcerated  is  much  swollen,  congested, 
softened,  and  commonly  presents  minute  haemorrhagic  foci.  Often, 
however,  the  entire  mucous  membrane  is  yellowish-green,  much 
discolored,  and  resembles  a  false  membrane.  At  times  there  is  a 
single  ulcer;  at  times  several  that  vary  in  size  and  situation.  The 
ulcers  may  be  situated  anywhere  along  the  length  or  circumference 
of  the  organ.  They  usually  correspond  in  location  to  the  areas  of 
discoloration  visible  on  the  external  aspect,  though  some  ulcers, 
particularly  if  they  be  superficial,  may  reveal  no  external  indications 
of  their  presence.  They  are  rather  common  opposite  the  attachment 
of  the  meso-appendix,  probably  because  in  this  situation  the  blood 
supply  is  poorest.  These  ulcers  may  be  round,  ovoid,  elongated, 
or  irregular  in  outline.  They  may  involve  one,  two,  three,  or  all  of 
the  coats  of  the  appendix.  They  usually  have  sloping  edges,  in 
that  the  greatest  destruction  of  tissue  is  at  the  surface — the  mucous 
membrane.  At  times,  however,  and  not  infrequently  in  the  early 
stages,  excessive  swelling  and  oedema  of  the  tissues  obscure  or 
completely  efface  this  character  of  the  ulcer.  It  is  merely  a  question 
of  the  severity  of  the  pathological  lesions,  and  to  some  extent  also  of 
the  duration  of  the  disease,  whether  the  ulcerative  condition  goes  on 
to  perforation  or  not.  Many  cases  of  non-perforative  ulcerative 
appendicitis  in  which  the  appendix  is  excised  early  would,  if  operation 
were  deferred,  progress  to  perforation.  The  surface  of  the  ulcer  is 
usually  intensely  red.  Not  uncommonly,  however,  it  is  of  a  greenish- 
yellow  or  greenish-black  color,  and  is  covered  with  discolored 
purulent  or  purulent  faecal  matter;  when  this  is  removed  by  irrigation, 
the  surface  of  the  ulcer  is  seen  to  be  the  seat  of  haemorrhagic  suffusion. 
If  perforation  has  occurred,  the  ragged  edges  of  the  opening  are  also 
visible.  In  the  neighborhood  of  the  ulceration- — or,  more  particu- 
larly, of  the  perforation,  if  this  has  occurred — an  appendicular 
calculus  may  be  detected.  Not  infrequently  this  will  be  found 
occupying  a  site  directly  over  the  ulceration;  often  enough,  however; 


Pathology  95 

just  above,  and  less  commonly  below,  the  latter.  Exceptionally,  it 
will  be  found  within  the  perforation,  partly  or  completely  occluding  it, 
and  in  a  fair  proportion  of  cases  of  perforation  diligent  search  will 
often  be  rewarded  by  the  discovery  of  the  calculus  in  the  exudate  or 
pus  surrounding  the  appendix. 

Although  it  is  generally  held  that  appendicular  calculi — other- 
wise spoken  of  as  faecal  concretions— are  common  in  this  variety  of 
appendicitis,  statistics  differ  widely  as  to  the  frequency  of  their 
occurrence.  They  were  found  in  28  (22.3  per  cent.)  of  120  of  the 
cases  that  I  examined.  Of  these  120  cases,  56  were  non-perforative, 
and  calculi  were  found  in  9  (16  per  cent.);  64  were  perforative,  and 
calculi  were  found  in  19  (29.8  per  cent.).  There  can  hardly  be  much 
question,  however,  that  they  are  more  frequently  present  than  these 
latter  figures  indicate.  The  foregoing  statistics  include  only  those 
cases  in  which  the  calculus  was  detected  in  the  appendix  when  it  was 
examined  in  the  laboratory. 

Reference  has  been  made  to  the  fact  that  in  certain  cases  of  ulcera- 
tive appendicitis  with  perforation  the  calculus  may  have  escaped 
from  the  appendix  before  the  time  of  operation  or  necropsy;  in  these 
cases  its  presence  may  be  undetected  at  the  subsequent  examination. 
There  is  thus  no  doubt  that  the  foregoing  figures  do  not  indicate 
the  exact  frequency  of  calculi  in  ulcerative  appendicitis  with  perfora- 
tion. On  the  other  hand,  it  is  believed  that  more  or  less  inspissated 
faecal  matter  has  been  classed  by  some  surgeons  as  fsecal  concretions, 
and  that  this  fact  serves  to  indicate  in  their  statistics  a  greater  fre- 
quency of  calculi  than  is  actually  the  case.  Such  inspissated  faecal 
matter  is  quite  common,  but  in  this  statistical  study  of  the  subject 
has  been  ignored,  only  well-formed  calculi  being  considered. 

Perforation  of  the  appendix  results  from  the  direct  necrotic 
action  of  bacteria  and  their  toxins,  or  from  the  mechanical  action 
of  calculi,  or  from  the  combined  action  of  both.  Exceptionally,  it 
results  from  the  bursting  of  an  empyema,  but  under  such  circum- 
stances the  rupture  is  not  unconnected  with  the  activities  of  bacteria. 
Perforation  of  the  organ  is  favored  by  anaemia,  due  to  withdrawal 
of  the  proper  blood  supply.  This  may  be  the  consequence  of  twists, 
flexures,  or  angulations  of  the  organ;  of  the  action  of  external 
cicatricial  bands  of  adhesions;  of  thrombo-arteritis  or  thrombo- 
phlebitis ;  or  of  a  combination  of  any  of  these  factors.     Predominance 


96  Appendicitis 

in  causing  perforation  of  the  appendix  must,  however,  be  accorded 
bacteria.  Calculi,  nevertheless,  are  of  considerable  significance; 
but  it  is  not  warrantable  to  state  that  they  must  have  been  operative 
in  all  cases,  assuming  in  those  cases  in  which  they  were  not  found 
that  they  must  have  been  overlooked  or  must  have  become  disinte- 
grated in  the  pus  or  exudate.  They  are  often  of  decisive  importance 
in  determining  the  site  of  the  perforation. 

Perforation  of  the  appendix  may  occur  into  preformed  peri- 
toneal adhesions,  and  give  rise  to  a  circumscribed  peri-appendicular 
abscess.  If,  however,  the  perforation  ensue  very  early  in  the  course 
of  the  affection,  before  the  peritoneum  has  had  time  to  set  up  reactive 
adhesions,  the  contents  of  the  appendix  are  evacuated  into  the  gen- 
eral peritoneal  cavity,  and  there  results  a  diffusing  peritonitis,  of 
which  mention  will  be  made  subsequently.  Again,  perforation  may 
occur  into  the  meso-appendix,  and  the  contents  of  the  appendix, 
liberated  and  dissecting  up  the  two  layers  of  this  structure,  may 
eventually  reach  the  retro-peritoneal  connective  tissue  and  there  pro- 
duce a  retro-peritoneal  abscess.  Under  some  circumstances  the 
appendix  has  formed  attachments  with  various  organs,  and,  in  the 
event  of  perforation  of  the  appendix,  the  ulcerative  process  may  con- 
tinue also  into  these.  If  the  organ  in  question  be  hollow,  the  ulcera- 
tive process,  invading  first  the  superficial  layers  of  the  appendix, 
finally  its  serous  coat,  then  the  serous  coat  of  the  hollow  organ 
(intestine),  until  ultimately  its  mucous  coat  is  perforated,  produces  a 
himucous  fistula.  As  it  is  the  caecum  with  which  the  appendix  most 
frequently  forms  adhesions,  so  also  is  it  the  caecum  that  is  most  fre- 
quently perforated  in  this  manner.  But  cases  have  been  reported 
in  which  perforation  occurred  into  the  duodenum  and  other  portions 
of  the  intestinal  tract.  In  addition,  Keen,  Bossard,  Dalmer  and 
Pilcher  report  cases  in  which  perforation  occurred  into  the  bladder. 
In  Keen's  and  Pilcher's  cases  the  appendix  became  permanently 
adherent  to  the  bladder,  and  a  urinary  fistula  resulted;  in  Bossard's 
dase  a  calculus  was  evacuated  from  the  appendix  into  the  bladder 
and  formed  the  nucleus  of  what  later  became  a  good-sized  vesical 
calculus.  In  Dalmer's  case  a  faecal  concretion  1.5  cm.  long  was 
passed  per  urethra  and  later  spontaneous  healing  of  the  fistula  took 
place. 

It  must  be  borne  in  mind  that  even  deep  ulceration  and  gangrene 


Pathology  97 

do  not  of  necessity  lead  to  immediate  perforation  of  the  appendix. 
In  many  such  cases  there  results  first  either  a  more  or  less  circum- 
scribed or  generalized  peritonitis,  with  slight  or  well-marked  intoxi- 
cation, and  the  patient  dies,  or  the  appendix  is  removed  by  operative 
measures  before  perforation  has  ensued.  Naturally,  however, 
under  such  circumstances  it  is  but  a  question  of  time  when  perforation 
occurs. 

In  all  cases  of  typhoid  fever  in  which  morbid  alterations  occur 
in  the  large  intestine  it  is  very  probable  that  examination  of  the 
appendix  would  reveal  similar  changes;  and  it  is  likely,  also,  that  in 
some  cases  in  which  the  lesions  in  the  large  intestine  are  inconspicu- 
ous those  in  the  appendix  may  be  quite  marked.  Catarrhal  altera- 
tions are  usually  well  developed,  and  during  the  acme  of  the  disease 
lesions  of  the  lymphoid  tissues  are  prone  to  be  conspicuous.  At 
times  these  assume  such  predominance  as  to  give  rise  to  concurrent 
appendicitis — typhoid  appendicitis.  Rarely,  perforation  may  ensue, 
and  a  circumscribed  or  diffuse  peritonitis  may  result.  The  sequels 
of  such  typhoid  ulcerations — such  as  strictures,  etc. — are  often  of 
considerable  moment  in  the  subsequent  production  of  an  attack  of 
appendicitis. 

Microscopy. — In  ulcerative  appendicitis  the  pathological  al- 
terations already  detailed  in  connection  with  catarrhal  and  inter- 
stitial appendicitis  are  present,  but  in  much  exaggerated  degree. 
There  are  excessive  dilatation  and  overfilling  of  the  blood-vessels, 
and  marked  serous,  cellular,  and  haemorrhagic  infiltration  of  the 
coats  of  the  appendix.  In  the  cellular  exudate  polynuclear  leuco- 
cytes predominate,  and  many  of  these  present  all  gradations  of 
retrograde  metamorphosis.  The  necrosis  may  result  in  one  of  two 
ways :  It  may  commence  by  erosion  and  necrosis  of  the  mucous  lining 
of  the  organ,  and,  having  involved  and  destroyed  the  basement 
membrane  of  the  latter,  may  successively  invade  and  destroy  the 
subjacent  coats — the  submucous,  muscular,  and  subserous  tissue — 
until  finally  the  peritoneal  covering  may  be  implicated,  perforation 
ensuing.  Less  commonly,  as  detailed  in  connection  with  the  inter- 
stitial form  of  appendicitis,  an  abscess  situated  beneath  the  unbroken 
mucous  membrane  develops.  It  may  be  situated  in  the  submucous, 
the  muscular,  or  the  subserous  coat,  and,  depending  upon  its  situa- 
tion, the  subsequent  events  vary.  If  it  be  situated  in  the  submucous 
7 


98  Appendicitis 

coat,  as  it  increases  in  size  it  at  first  encroaches  upon,  and  finally 
occludes,  the  lumen.  The  epithelial  cells  of  the  mucous  membrane 
already  participating  in  the  inflammation  become  deprived  of  their 
proper  nutritive  supply,  and  as  a  consequence  of  this,  and  also  of 
pressure  from  the  abscess,  they  degenerate.  The  abscess  finally 
ruptures  into  the  lumen  of  the  organ  and  an  ulcerated  surface  re- 
mains. This  ulceration  may  then  progress  until  all  the  coats  of  the 
appendix  are  involved,  and  perforation,  as  in  the  aforementioned  case, 
may  eventually  ensue.  This  submucous  abscess  may  develop  in 
the  submucous  connective  tissue  by  liquefaction  necrosis  of  the 
inflammatory  exudate,  or  it  may  result  from  necrosis  of  one  or  more 
of  the  lymphoid  follicles,  as  previously  stated.  If,  on  the  other  hand, 
the  interstitial  abscess  be  situated  near  the  peritoneal  covering, 
increasing  in  size,  it  may  finally  perforate  externally:  that  is,  into  sur- 
rounding fibrinous  exudate  or  into  the  general  peritoneal  cavity. 
Under  such  circumstances,  as  stated  in  connection  with  the  macro- 
scopy,  there  ensues  a  perforation  or  rupture  of  the  wall  of  the  appen- 
dix without  any  communication  being  established  between  the  lumen 
and  the  exterior  of  the  organ — no  opportunity  is  afforded  for  the 
escape  of  faecal  matter  into  the  peritoneal  cavity.  The  process  of 
ulceration  thus  inaugurated  may  progress,  and  a  communication  with 
the  lumen  may  be  subsequently  established. 

The  liquefaction  necrosis  of  the  inflammatory  exudate  and  of  the 
appendicular  tissues  may  be  quite  extensive,  having  developed 
rapidly,  before  there  is  any  evidence  of  it  macroscopically.  The 
cell  nuclei  no  longer  stain  well;  they  present  chromatolysis,  karyor- 
rhexis,  or  hyperchromatosis;  the  cell  protoplasm,  plasmolysis;  and, 
finally,  the  entire  area  becomes  a  mass  of  granular  debris.  To  this 
fluid  is  added  and  the  focus  disintegrates  entirely  and  is  discharged 
into  the  lumen  of  the  appendix,  leaving  usually  an  extensive  ulcer. 
At  times  the  process  of  ulceration  is  not  so  rapid;  the  necrotic  tissue 
maintains  some  connection  w^ith  the  underlying  tissues,  and  much  re- 
sembles, upon  superficial  examination,  a  false  membrane.  In  all 
cases  of  ulcerative  appendicitis  hsemorrhagic  foci  are  a  conspicuous 
feature.  At  times  these  are  quite  small — microscopical.  Again, 
they  are  extensive,  evident  to  the  unaided  eye,  and  lead  to  the  utmost 
destruction  of  the  appendix.  Entire  layers  of  the  several  coats  are 
separated   by    the    infiltrating   blood,    and    excessive    disturbance 


Pathology  99 

of  the  topographical  relations  ensues.  At  times  the  blood  is  found  to 
be  in  a  good  state  of  preservation;  again,  it  is  more  or  less  disinte- 
grated, or  is  represented  by  blood  pigment.  Proliferation  of  the 
endothelial  lining  of  the  blood-vessels  is  evident  in  a  certain  pro- 
portion of  the  cases. 

GANGRENOUS  APPENDICITIS. 

By  gangrenous  appendicitis  is  understood  an  inflammation  or 
infection  of  the  appendix  attended  by  gangrene.  This  variety  of 
appendicitis  has  often  been  referred  to  as  infectious,  under  the  mis- 
taken apprehension  that  it  only,  in  contradistinction  to  the  other 
varieties,  is  due  to  bacterial  infection.  The  frequency  of  this  variety 
of  appendicitis  is  indicated  by  the  fact  that  of  239  cases  of  acute 
appendicitis  examined,  50  were  of  the  gangrenous  variety. 

Gangrenous  appendicitis,  or  gangrene  of  the  appendix,  may  arise 
in  one  of  several  ways.  In  the  first  place,  as  before  indicated,  any 
of  the  previously  described  varieties  of  inflammation  of  the  appendix 
may  progress  to  gangrene.  While  this  eventually  may  ensue  in  the 
course  of  an  inflammation  that  commenced  as  a  catarrh,  be  it  acute 
or  chronic,  it  is  much  more  likely  to  follow  the  severer  forms  of 
inflammation  of  the  organ.  In  fact,  in  the  event  of  gangrene  we  are 
usually  justified  in  assuming  a  sudden  severe  infection  in  an  appen- 
dix already  the  seat  of  disease.  On  the  other  hand,  a  sudden  severe 
infection,  by  virulent  bacteria  or  their  toxins,  of  a  previously  healthy 
appendix  may  occur.  This  infection  may  be  so  intense  and  so  over- 
whelming as  to  lead  to  rapid  and  fatal  gangrene,  possibly  of  the  entire 
appendix,  before  an  opportunity  has  been  afforded  the  tissues  to  set 
up  counteracting  inflammation.  Exceptionally,  infection  may  be  so 
intense  as  to  lead  to  the  death  of  the  patient  before  necrosis  has 
become  marked  or  peritonitis  has  developed.  It  is,  however,  merely 
a  matter  of  time  until  the  necrosis  becomes  absolute  and  peritonitis 
of  a  virulent  type  supervenes.  Again,  gangrene  of  the  appendix 
may  be  caused  by  sudden  and  complete  withdrawal  of  the  blood 
supply  from  the  entire  organ  or  from  part  of  it.  This  may  be  in- 
duced by  twists,  angulations,  etc.,  or  may  follow  thrombo-phlebitis 
or  thrombo-arteritis  consequent  upon  interstitial  or  ulcerative 
appendicitis. 

Macroscopy. — If  the  gangrene  occur  in  the  sequence  of  ulcera- 


TOO  Appendicitis 

tive  appendicitis,  the  naked-eye  appearances  detailed  in  connection 
with  that  variety  of  appendicitis  are  considerably  exaggerated,  both 
in  degree  and  extent.  A  quarter,  a  third,  a  half,  even  the  entire 
organ,  may  assume  a  dirty  greenish-black  color;  it  may  become 
swollen,  malodorous,  and  softened,  and  may  finally  become  detached 
from  the  remainder  of  the  organ  or  from  the  caecum,  as  the  case 
may  be.  The  gangrenous  area  presents  the  appearance  of  moist 
gangrene  generally.  That  region  from  which  the  gangrenous  area 
has  become  separated  by  ulceration  is  reddened,  raw,  haemorrhagic, 
and  the  seat  of  newly  formed  granulations.  The  remainder  of  the 
appendix,  if  the  entire  organ  is  not  gangrenous,  presents  the  appear- 
ances detailed  in  connection  with  the  macroscopy  of  interstitial 
and  ulcerative  appendicitis. 

If  the  gangrene  be  the  result  of  sudden  acute  infection,  at  the 
end  of  a  short  time — from  twenty-four  to  forty-eight  hours— the 
entire  organ  or  a  portion  of  it  may  be  completely  deprived  of  its 
vitality.  The  same  thing  may  happen  if  the  blood  supply  be 
withdrawn.  The  portion  of  the  organ  affected  is  distinctly  greenish- 
black  in  color;  it  is  increased  in  bulk,  much  softened,  and  of  a 
characteris-tic  gangrenous  odor.  It  may  still  be  attached  to  the 
remaining  portion  of  the  appendix  or  to  the  caecum,  and  if  but  a 
portion  be  affected,  the  remainder  is  in  a  high  state  of  interstitial 
inflammation,  and  is  separated  from  the  gangrenous  area — ^at 
least,  after  the  condition  has  existed  for  some  time — ^by  a  more  or 
less  well-developed  line  of  demarcation. 

In  this  variety  of  appendicitis  the  pathological  alterations  and 
the  clinical  manifestations  may  develop  with  such  rapidity  as  well 
to  merit  the  designation  fulminating  appendicitis.  There  may  occur 
within  a  short  time  a  complete  circular  amputation  of  the  entire 
appendix  or  gangrene  of  a  considerable  portion  of  it — conditions 
that  have  been  spoken  of  as  sloughing  of  the  appendix.  In  some  such 
cases  sufficient  time  has  not  elapsed  for  the  formation  of  peritoneal 
adhesions,  and  thus — ^in  contradistinction  to  the  other  varieties  of 
appendicitis,  in  which  the  organ  is  commonly  surrounded  and 
more  or  less  fixed  by  adhesions — the  appendix  may  be  found  to  be 
totally  gangrenous,  completely  detached  from  the  caecum,  and  free 
in  the  peritoneal  cavity.  In  other  cases  it  may  be  found  separated 
from  the  appendix  and  free  in  a  circumscribed  abscess. 


Pathology  loi 

The  matter  exuding  from  the  opened  himen  of  such  gangrenous 
appendices  is  usually  pus.  At  times  appendicular  calculi  may  be 
found,  either  in  the  lumen,  projecting  from  it,  or  in  the  surrounding 
purulent  matter  or  exudate.  In  49  of  the  cases  of  gangrenous 
appendicitis  examined  they  were  found  in  5  (10.2  per  cent.).  Doubt- 
less others,  however,  at  the  time  of  operation  had  already  escaped 
from  the  appendix  and  were  not  detected  in  the  surrounding  exudate 
or  pus.  As  already  indicated,  the  gangrene  may  affect  the  whole 
or  a  portion  of  the  appendix.  There  may  occur  a  circular  amputa- 
tion anywhere,  or  but  a  portion  of  the  circumference  may  be 
involved. 

After  spontaneous  amputation  the  appendix  occasionally  escapes 
necrosis,  being  nourished  either  by  the  appendiceal  artery  or  by 
newly  formed  vessels  from  the  surrounding  exudate.  The  mucous 
membrane  may  then  be  the  source  of  a  persistent  mucous  fistula, 
which  can  be  healed  only  by  the  complete  removal  of  the  remnants 
of  the  appendix. 

Most  unusual  and  remarkable  conditions  are  sometimes  encoun- 
tered. An  instructive  instance  is  the  case  in  which,  at  a  secondary 
operation  for  the  cure  of  two  fistulous  tracts  persisting  after  a  pri- 
mary operation,  the  appendix  was  found  to  consist  of  the  tip  con- 
nected with  the  proximal  half  by  a  band  of  the  meso-appendix. 
The  opening  in  the  appendix  was  in  communication  with  the  two 
fistulous  tracts.  Jopson  reports  a  somewhat  similar  case,  a  fistula 
from  which  there  was  a  profuse  mucous  discharge. 

Microscopy. — ^Those  portions  of  the  appendix  actually  the 
seat  of  gangrene  naturally  present  no  structure  that  can  be  identified 
with  certainty.  Other  portions  of  the  organ  present  all  gradations 
from  moderate  interstitial  inflammation  and  ulceration  to  actual  gan- 
grene. If  gangrene  follow  catarrhal  or  interstitial  inflammation  with 
ulceration,  in  certain  regions — unless  the  entire  appendix  is  already 
gangrenous — there  is  more  or  less  extensive  destruction  of  the  surface 
epithelium,  and  to  some  extent  also  of  the  protecting  basement 
membrane.  It  is  not  improper  to  assume  that  this  latter  structure 
is  of  considerable  importance  in  protecting  against  infection.  The 
exposed  and  unprotected  mucosa  and  submucosa  afford  a  congenial 
soil  whence  infection  of  the  entire  wall  is  a  matter  readily  accom- 
plished.    In  addition,  there  are  noticeable  high  grades  of  interstitial 


I02  Appendicitis 

inflammation,  with  abundant  round-cell  infiltration,  suppurative 
foci,  larger  and  smaller  areas  of  haemorrhage,  and  more  or  less 
extensive  necrosis.  The  individual  cells  present  plasmolysis,  chro- 
matolysis,  karyorrhexis,  and  hyperchromatosis.  Adipose  tissue 
becomes  converted  into  free  fat  and  fatty  acids,  muscle  fibres  become 
indistinct  and  dissolved,  and  the  entire  tissue  breaks  down  into  a 
granular  and  semi-fluid  debris.  Haemorrhages  ensue,  either  from 
erosion  of  the  vessels  or,  not  uncommonly,  from  the  result  of  the 
direct  action  of  the  bacteria  and  their  toxins  on  the  vessel  walls. 
If  a  line  of  demarcation  have  formed,  it  presents,  on  the  one  hand, 
all  the  evidences  of  liquefaction  necrosis  until  the  sphacelus  is  cast 
ofF;  and,  on  the  other,  the  ordinary  evidences  of  inflammatory 
reaction — commonly,  however,  with  but  slight  manifestations  of 
regeneration.  If  the  gangrene  be  the  consequence  of  sudden  severe 
infection  with  very  virulent  bacteria,  or  of  the  sudden  and  complete 
withdrawal  of  the  blood  supply  consequent  upon  twists,  flexures, 
thrombo-phlebitis,  or  thrombo-arteritis,  the  entire  appendix  or  a 
large  portion  of  it  presents  evidences  of  very  diffuse  gangrene  without 
manifestations  of  reactive  inflammation.  Under  such  circumstances 
the  gangrene  affects  a  large  portion  of  the  appendix  uniformly,  and 
does  not  appear  to  have  been  the  result  of  the  progression  of  the 
other  varieties  of  inflammation  of  the  appendix.  The  deeper  layers 
of  the  organ  are  quite  as  much  involved  as  the  superficial. 

CHRONIC  APPENDICITIS. 

In  some  presumably  diseased  appendices,  particularly  in  some 
of  those  removed  from  patients  presenting  clinical  evidence  of 
chronic  appendicitis,  histological  alterations  are  not  especially 
conspicuous.  In  a  few  instances  they  are  not  more  marked  than 
are  those  sometimes  detected  in  appendices  removed  at  necropsy 
from  subjects  who  during  life  presented  no  definite  indications  of 
appendicitis.  In  some  cases  the  only  tangible  and  unmistakable 
evidences  of  disease  are  peritoneal  adhesions  binding  the  appendix 
to  various  tissues  or  organs.  Thus,  the  query  naturally  arises: 
When  is  the  appendix  to  be  regarded  as  pathological?  It  need 
hardly  be  stated  that  in  a  number  of  cases,  especially  of  chronic 
appendicitis,  a  microscopical  examination  of  the  organ  must  be 


Pathology  103 

made  before  a  trustworthy  opinion  as    to    its    condition   can   be 
formulated. 

In  many  instances  disease  of  the  appendix  has  been  detected 
postmortem  in  subjects  who  during  life  manifested  no  noteworthy 
clinical  evidences  of  such  deviations  from  the  normal.  Thus, 
Kraussold  states  that  one-third  of  all  adult  bodies  reveal  diseased 
appendices;  Toft  found  the  appendix  diseased  in  100  out  of  300 
subjects  upon  whom  he  performed  necropsies;  Hawkins  detected 
evidences  of  past  or  present  disease  of  the  appendix  in  16  out  of 
100  subjects.  Personally,  I  believe  that  careful  macroscopical  and 
microscopical  investigation  will  reveal  indications  of  disease  in  at 
least  one-third  of  presumably  normal  appendices  removed  from 
adults.  Kelynack,  on  the  other  hand,  believes  that  the  statistics 
of  Ransohoff — who  found  diseased  appendices  in  8  out  of  60  subjects 
—represent  more  nearly  the  usual  proportion.  In  many  of  these 
cases  there  can  hardly  be  any  question  that  the  patients  did  not 
present  any  evidences  of  serious  disease;  on  the  other  hand,  the 
appendix  cannot  be  regarded  as  normal.  It  is  not  likely  that  the 
lesions  began  acutely;  rather,  they  commenced  chronically,  insidi- 
ously, and  it  is  but  fair  to  assume  that,  had  the  patients  lived  long 
enough,  or  had  an  appropriate  infection  occurred,  they  would 
inevitably  have  suffered  the  evil  consequences  of  these  morbid 
changes.  In  other  cases  the  patients  complain  of  various  indefinite 
abdominal  symptoms  that  are  referred  to  disease  of  one  or  another 
of  the  abdominal  organs.  At  times,  however,  the  affection  is 
recognized  as  chronic  appendicitis,  and  the  good  effects  attending 
operation  for  the  excision  of  the  offending  organ  sufficiently  attest 
that  even  minor  pathological  alterations  of  the  appendix  may  give 
rise  to  more  or  less  aggravated  and  persistent  clinical  symptoms. 
Many  of  these  cases  doubtless  belong  to  the  class  that  Ewald  has 
incorrectly  designated  appendicitis  larvata.  Rather  should  they  be 
termed  cases  of  appendicitis  difficult  of  diagnosis.  They  should 
not  be  confounded  with  those  cases  that  Nothnagel,  among  others, 
has  described  under  the  caption  of  hysterical  mimicry  of  appendi- 
citis. The  hysterical  nature  of  a  case  of  suspected  appendicitis 
should  not  be  especially  difficult  of  recognition. 

Many  patients  not  in  the  least  hysterical  suffer  severely  and 
repeatedly  from  more  or  less  aggravated  attacks  of  recurring  appen- 


I04  Appendicitis 

dicitis;  and  still,  in  some  instances,  the  appendix,  when  excised, 
presents  but  minor  pathological  alterations.  Doubtless  in  some 
cases  the  inflammatory  phenomena  subside  with  greater  or  less 
rapidity,  and  in  the  absence  of  extensive  histological  evidence  of 
disease,  it  is  not  always  warrantable  to  assert  that  the  removal  of 
a  given  appendix  was  not  justified.  It  must  further  be  admitted, 
in  view  of  the  difficulty  sometimes  experienced  in  distinguishing 
between  the  results  of  inflammatory  disease  and  certain  develop- 
mental anomalies  and  retrograde  alterations,  that,  in  certain  isolated 
cases,  the  clinical  history  is  of  decisive  importance.  All  of  the  fore- 
going, however,  are  exceptional  cases.  Ordinarily,  there  is  no 
difficulty  whatever  in  recognizing  the  lesions  of  chronic  appendicitis. 

CHRONIC  CATARRHAL  APPENDICITIS. 

By  chronic  catarrhal  appendicitis  is  understood  a  chronic  inflam- 
mation of  the  appendix  in  which  the  pathological  alterations  are 
wholly  or  almost  wholly  confined  to  the  mucous  membrane,  the 
other  coats  presenting  little  or  no  deviation  from  the  normal.  This 
is  a  very  uncommon  variety  of  appendicitis,  for  the  reason  that  the 
causes  inducing  the  inflammation,  from  their  very  nature,  entail 
consequences  that  render  the  limitation  of  the  pathological  altera- 
tions to  the  mucous  membrane  extremely  unlikely.  There  can, 
however,  be  no  question  that  cases  of  catarrhal  appendicitis  do 
occur.  They  are  cases  that  clinically  pursue  a  mild  course,  being, 
possibly,  now  and  then  subject  to  minor  acute  exacerbations.  The 
clinical  history  of  some  cases  of  appendicitis  indicates  the  existence 
of  appendicular  disease  for  a  considerable  period  of  time,  and  yet 
examination  of  the  excised  appendix  reveals  only  catarrhal  lesions. 
The  occurrence  of  such  cases  has  been  indicated  by  various  observers 
from  time  to  time  and  1.7  per  cent,  of  the  chronic  cases  that  were 
examined  were  of  this  variety. 

Macroscopy. — Macroscopical  examination  shows  the  appendix 
to  be  a  little  thicker,  stiffer,  and  firmer  than  normal.  On  incising 
it,  the  mucous  membrane  is  found  to  be  of  a  grayish  color  and  some- 
what thickened.  The  crypts  of  Lieberkiihn  are  moderately  dis- 
tended and  the  mucous  membrane  is  covered  with  a  layer  of  rather 
thick  mucus.     This  mucus  may  also  fill  more  or  less  completely  the 


Pathology  105 

lumen  of  the  organ.  There  is,  however,  commonly  associated  with 
the  mucus,  some  fsecal  matter,  or,  rarely,  a  calculus.  The  calibre 
of  the  lumen  may  vary  somewhat  at  different  levels,  usually  as  a 
result  of  previous  attacks  of  inflammation.  If  to  such  chronic 
catarrhal  inflammation  there  be  added  an  acute  exacerbation,  the 
evidences  of  the  latter,  as  already  narrated,  will  be  manifest. 

Microscopy. — ^The  crypts  of  Lieberkiihn  are  more  or  less 
distended  with  mucus,  and  some  mucous  droplets  are  also  seen 
in  the  epithelial  cells  lining  these  crypts  and  the  lumen  of  the 
organ.  Naturally,  these  are  not  so  conspicuous  as  in  the  acute 
variety.  In  the  mucosa  there  are  a  few  round  cells  and  spindle 
cells  and  connective-tissue  hyperplasia.  At  times  the  vessel  walls 
of  this  region  are  thickened,  and  there  may  be  some  foci  of  blood 
pigm.ent. 

It  is  extremely  improbable  that  in  chronic  inflammation  of  the 
appendix  the  lesions  will  remain  indefinitely  localized  to  the  mucous 
membrane.  They  tend  to  become  diffuse,  constituting  chronic 
interstitial  appendicitis. 

CHRONIC  INTERSTITIAL  APPENDICITIS. 

By  chronic  interstitial  appendicitis  is  understood  a  chronic 
inflammation  of  the  appendix  in  which  all  the  coats  of  the  organ 
are  involved.  In  certain  instances  one  or  more  coats  exhibit 
pathological  alterations  out  of  proportion  to  those  of  others,  but 
usually  deviations  from  the  normal,  more  or  less  conspicuous, 
may  be  detected  in  all.  This  is  the  common  variety  of  chronic 
appendicitis.  In  fact,  excepting  those  relatively  rare  cases  in 
which  the  lesions  are  strictly  confined  to  the  mucous  membrane, 
and  others  due  to  certain  specific  micro-organisms — such  as  the 
tubercle  bacillus,  etc.— all  cases  of  chronic  appendicitis  are  of  the 
interstitial  variety.  These  are  the  cases  clinically  spoken  of  as 
chronic  appendicitis,  relapsing  appendicitis,  recurring  appendicitis, 
etc.  Clinically  and  pathologically,  it  suffices  to  designate  them 
chronic  appendicitis.  Of  course,  an  acute  exacerbation  may 
develop  at  any  time.  Of  the  305  cases  of  chronic  appendicitis 
examined,  299  were  of  the  interstitial  variety,  6  of  these,  however, 
being  of  the  subclass  designated  obliterating  appendicitis. 

Macroscopy. — ^The  naked  eye  appearances  vary  considerably 


io6  Appendicitis 

in  different  cases.  The  simplest  form  is  that  in  which  the  condition 
follows  the  subsidence  of  a  minor  grade  of  acute  inflammation, 
or  in  which  the  process  commences  as  a  chronic  inflammation, 
the  lesions  not  being  limited  to  the  mucous  membrane.  The 
organ  is  thicker,  stiffer,  and  firmer  than  normal,  and  is  non-collaps- 
ible. The  appearances  of  its  mucous  membrane  and  contents  do 
not  differ  especially  from  those  described  in  connection  with  chronic 
catarrhal  appendicitis.  At  times  the  lumen  is  much  reduced, 
varies  in  calibre  in  different  regions,  and  contains  one  or  more 
calculi.  Of  252  of  the  chronic  cases  examined,  calculi  were  noted 
in  39  (15.5  per  cent.).  Whether  the  lesions  are  confined  to  the 
mucous  membrane,  or  are  distributed  throughout  all  the  coats, 
is  at  times  determinable  only  upon  microscopical  examination. 
Again,  however,  the  walls  are  excessively  thick,  and  justify  the 
inference  that  the  lesions  are  widespread.  In  a  great  number  of 
cases  I  have  found  the  external  diameter  of  the  appendix  to  be 
from  12  to  14  mm.  and  more,  and  the  lumen  less  than  2  mm. 

Reference  has  been  made  to  the  frequency  of  erosions  and 
ulceration  of  the  appendix  in  cases  of  acute  inflammation,  and 
it  was  stated  that  if  the  inflammation  were  not  very  intense,  the 
acute  manifestations  might  subside,  the  process  becoming  chronic. 
Under  such  circumstances  certain  important  results  ensue.  That 
portion  of  the  wall  of  the  appendix  which  is  the  seat  of  erosion  or 
ulceration  is  replaced  by  newly  formed  connective  tissue,  which 
like  all  newly  formed  connective  tissue,  tends  to  contract  and  to 
form  cicatricial  tissue.  As  a  consequence  the  lumen  becomes 
contracted.  If  there  have  been  several  points  of  ulceration,  there 
will  also  be  several  points  of  stenosis  of  the  lumen.  Depending 
upon  the  situation,  size,  and  shape  of  these  cicatrices,  there  results 
either  a  transverse  narrowing  of  the  lumen,  or,  particularly  if  the 
cicatrix  be  longitudinal  rather  than  annular,  there  will  ensue  a 
shortening  of  the  organ  along  one  side — a  curling-up  of  the  appendix, 
or  an  angulation,  flexure,  twist,  etc.  If  there  be  several  cicatrices, 
the  utmost  distortion  of  the  appendix  may  be  produced,  and  the 
lumen  of  the  organ  may  be  represented  by  several  cavities  separated 
from  one  another  by  areas  of  constriction.  It  is  in  those  portions 
of  the  lumen  limited  by  stenosis  that  appendicular  calculi  are 
particularly  liable  to  be  encountered.     Not  infrequently  they  give 


Pathology  107 

rise  to  chronic  erosion  and  ulceration.  It  must  be  borne  in  mind 
that  such  ulceration  may  also  be  due  to  causes  other  than  calculi, 
as,  for  instance,  tuberculosis,  bacterial  toxins,  acute  exacerbations 
of  inflammation,  etc. 

On  the  other  hand,  there  may  be  complete  obliteration  of  the 
lumen  of  the  appendix  at  one  or  more  points  along  its  length.  It 
is  readily  conceivable  that  in  the  event  of  annular  ulceration, 
granulating  surfaces  being  everywhere  apposed  to  granulating 
surfaces,  these  adhere,  and,  as  the  processes  of  regeneration  and 
organization  go  on,  become  permanently  united  by  means  of  newly 
formed  connective  tissue.  Such  obliteration  of  the  lumen  may  be 
circumscribed  or  generalized.  In  the  latter  case  obliterating 
appendicitis  results;  in  the  former,  merely  a  local  obliteration. 
The  latter  may  be  situated  anywhere,  and  not  uncommonly  gives 
rise  to  a  condition  known  as  cystic  dilatation,  retention  cyst,  hydrops, 
or  mucocele  (Fere)  of  the  appendix.  This  is  a  condition  in  which 
that  portion  of  the  appendix  distal  to  the  obliteration  becomes 
distended  and  filled  with  fluid.  It  was  first  recognized  by  Virchow, 
who  spoke  of  it  as  colloid  degeneration  of  the  appendix.  Depending 
upon  the  site  of  the  obliteration,  a  portion  of  the  appendix  or  the 
entire  organ  may  be  affected.  Commonly,  the  dilatation  is  confined 
to  the  distal  half  of  the  organ,  but  the  entire  organ  is  relatively 
often  involved.  Rarely,  a  central  portion  may  be  implicated, 
the  tip  and  proximal  portions  being  free.  Under  such  circumstances, 
however,  the  tip  is  much  more  likely  to  be  entirely  obliterated. 

These  cystic  dilatations  vary  much  in  size.  At  times  they 
are  not  much  larger  than  a  walnut,  but  instances  of  excessive  size 
have  been  reported.  Virchow  stated  that  they  might  reach  the 
size  of  a  large  fist.  One  removed  by  Deaver  from  a  woman, 
aged  twenty-five  years,  who  had  had  two  attacks  of  appendicitis, 
was  the  size  of  a  small  orange,  and  was  adherent  both  to  the  neigh- 
boring coils  of  small  intestine  and  to  the  right  broad  ligament. 
The  lumen  of  the  appendix  was  entirely  occluded  one-quarter  of 
an  inch  from  its  caecal  end. 

In  shape  they  may  be  ovoid,  cylindroid,  round,  or  irregular. 
The  character  of  the  contained  fluid  also  varies.  It  may  be  clear 
or  slightly  turbid,  tenacious,  gelatinous,  or  sometimes  more  limpid 
and  watery.     Leube  long  ago  drew  attention  to  the  fact  that  at 


io8  Appendicitis 

first  the  contained  fluid  consists  of  tenacious  mucus,  and  that 
it  later  assumes  the  characteristics  of  a  watery  serum.  This  ensues 
because  the  wall  of  the  appendix,  as  it  becomes  distended,  usually 
also  becomes  thinned,  its  inner  surface  growing  smooth  and  the 
distribution  of  its  vessels  being  more  superficial  than  normal. 
This  results,  on  the  one  hand,  in  facilitating  the  escape  of  the 
watery  portion  of  the  blood,  and,  on  the  other,  in  reducing  to  a 
minimum  the  formation  of  mucus. 

Some  very  unusual  conditions  have  been  reported.  Thus, 
Coats,  Weir,  and  Kelynack  have  observed  cases  in  which  the 
contents  were  gelatinous  in  character.  In  Kelynack's  case  "the 
appendix  was  greatly  distended,  and  presented  two  very  distinct 
diverticular  processes,  which  were  directed  beneath  the  folds  of 
the  mesentery  of  the  appendix.  The  diverticula  were  connected 
with  the  dilated  cavity  of  the  appendix  through  well-defined  circular 
openings."  Stengel  found  in  about  2000  autopsies  one  case  of 
true  mucoid  cyst  of  the  appendix.  He  describes  the  condition 
and  shows  it  to  differ  entirely  from  simple  mucocele  of  the  appendix, 
and  considers  it  as  being  possibly  allied  to  colloid  carcinoma. 
Hawkins  states  that  there  is  a  specimen  in  St.  Thomas's  Hospital 
Museum  that  shows  five  or  six  diverticula  on  the  surface  of  the 
cyst.  Werth,  Fraenkel  and  Neugebauer  have  described  cases  of 
multiple  "pseudocyst"  formation,  in  which  multiple  gelatinous 
globules  have  studded  the  appendix  and  even  the  surrounding 
visceral  serosa.  Hawkins,  Bland-Sutton,  and  Page  report  cases 
in  which  the  contents  consisted  of  purulent  matter;  but  these  were 
probably  ordinary  empyemas  of  the  appendix.  Fenwick  reports  a 
case  in  which  the  appendix  was  distended  by  a  "milky  fluid." 
Guttman  reports  a  case  in  which  the  dilatation  was  14  cm.  in 
length  and  21  cm.  in  its  greatest  circumference. 

Not  all  cases,  however,  are  due  to  obliteration  of  a  portion  of 
the  lumen  of  the  appendix;  sufficient  obstruction  may  be  produced 
by  a  very  acute  angulation.  An  instructive  case  of  this  sort  has 
been  reported  by  Treves  and  Swallow.  A  tumor  two  inches  in 
length  and  one  inch  in  diameter  was  made  up  of  the  appendix 
acutely  bent  upon  itself  and  distended  with  mucus.  The  angulation 
was  maintained  by  old  peritoneal  adhesions.  When  this  was 
relieved,  the  contents  escaped  of  their  own  accord. 


Pathology  109 

The  development  of  this  condition  of  cystic  dilatation  of  the 
appendix  depends  upon  several  factors.  The  obstruction  of  the 
lumen  must  be  complete,  or  almost  so;  the  obstruction  or  obliteration 
must  have  obtained  at  a  time  when  the  affected  portion  of  the  organ 
contained  no  pathogenic  micro-organisms;  the  mucous  membrane 
of  the  affected  portion  must  be  intact,  or  at  least  capable  of  func- 
tionating; and  the  secretion  by  the  mucous  membrane  must  be 
more  rapid  than  the  absorption  from  the  portion  of  the  appendix 
involved.  If  the  obstruction  be  not  complete,  the  secretion  is 
likely  to  be  forced  through  even  a  narrow  opening  with  sufficient 
rapidity  to  prevent  a  large  accumulation,  and,  on  the  other  hand, 
infection  is  likely  to  occur  through  the  patulous  lumen,  converting 
a  cystic  dilatation  into  an  empyema.  If  there  are  already  virulent 
bacteria  in  the  affected  portion  of  the  appendix,  an  empyema,  of 
course,  rather  than  a  cystic  dilatation,  will  develop  in  the  first 
place.  If  the  mucous  membrane  is  incapable  of  functionating, 
there  can  be  no  accumulation  of  fluid,  and  the  same  is  also  true 
if  absorption  be  more  rapid  than  secretion. 

The  condition  is  readily  recognized  as  cystic  dilatation  of  the 
appendix.  The  mucous  membrane  is  usually  smooth,  and  is 
generally  in  a  high  state  of  atrophy  as  a  consequence  of  mechanical 
pressure.  There  is  also  marked  atrophy  of  the  lymphoid  follicles. 
If  the  distention  be  but  moderate,  it  is  not  uncommon  to  find  the 
wall  much  thickened,  as  a  result  of  compensatory  hypertrophy  of 
the  muscular  coats,  and  also  of  some  connective-tissue  hyperplasia. 
Both  these  conditions,  as  evidences  of  chronic  inflammation,  as  is 
mentioned  elsewhere,  may  have  developed  prior  to  the  hydrops. 
If  with  the  occurrence  of  the  distention  the  wall  does  not  increase 
still  more  in  thickness,  it  is  likely  to  become  much  attenuated  under 
the  influence  of  the  progressive  accumulation  of  the  fluid. 

Microscopy. — ^The  microscopical  appearance  of  the  extirpated 
appendix  in  cases  of  chronic  appendicitis  varies  considerably  in 
different  instances.  In  some  cases  in  which  the  clinical  manifesta- 
tions have  extended  over  a  period  6i  some  years  the  microscopical 
evidences  of  disease  are  very  slight.  In  these  cases,  however,  the 
indications  of  disease  are  self-evident  from  the  macroscopical 
appearances,  the  distortions  of  the  organ,  and  the  chronic  peritoneal 
adhesions.     Even  in  these  cases,  however,  careful  microscopical 


no  Appendicitis 

examination  will  usually  detect  some  of  the  catarrhal  alterations 
already  detailed  in  connection  with  chronic  catarrhal  appendicitis 
and  some  hyperplasia  of  the  submucous  or  muscular  coats  or  of 
both.  In  addition,  more  or  less  round-cell  infiltration  will  com- 
monly be  noticeable.  In  other  cases  the  hyperplasia  of  the  sub- 
mucous and  muscular  coats  is  excessive,  and  there  is  considerable 
round-cell  infiltration,  which  is  usually  scattered  in  small  amounts 
throughout  the  various  coats.  If  the  lesions  of  the  mucous  mem- 
brane, already  referred  to,  are  not  present,  there  is  commonly  more 
or  less  atrophy  of  this  structure,  and  in  some  instances  it  is  replaced 
by  cicatricial  connective  tissue — the  lumen,  under  such  circum- 
stances, being  very  narrow.  In  most  cases  of  chronic  appendicitis 
a  hyaline  degeneration  of  the  submucous  and  muscular  coats  is  a 
rather  conspicuous  feature.  This  varies  in  extent  in  different 
cases,  at  times  being  minimal,  at  others  quite  diffuse.  If  the 
appendix  be  examined  while  the  process  of  cicatrization  of  an 
ulceration  is  in  progress,  remnants  of  the  mucous  membrane  may 
still  be  detected.  This,  however,  is  not  usual.  On  the  contrary, 
what  remains  of  the  mucous  membrane  and  submucosa  is  the 
seat  of  extensive  round-cell  infiltration,  which  is  present  also,  to  a 
greater  or  less  extent,  in  the  muscular  coats.  As  a  consequence 
of  this  round-cell  infiltration,  and  of  some  hyperplasia  of  the  sub- 
mucous and  muscular  coats,  the  wall  of  the  appendix  is  thickened 
and  non-collapsible,  and  peristalsis  is  inhibited.  Conditions  are 
favorable,  therefore,  for  the  approximation  of  the  opposed  granu- 
lating surfaces — the  free  edges  of  the  lumen — ^and  for  the  formation 
of  adhesions.  In  many  cases  delicate  strands  of  embryonic  con- 
nective tissue  may  be  seen  bridging  the  narrow  slit — remains  of 
the  lumen — ^and  uniting  the  opposed  surfaces.  In  the  early  stages 
of  this  process,  however,  these  strands  are  so  delicate  that  they  are 
frequently  torn  in  the  manipulations  necessary  in  preparing  the 
sections,  and  hence  may  be  overlooked.  Newly  formed  blood- 
vessels are  frequent,  and  about  these  there  spring  up  new  granula- 
tions, which  tend  to  cicatrization  and  to  the  formation  of  fibrous 
connective  tissue.  Obliteration  of  the  lumen  at  some  point  may 
now  be  complete.  Cicatrization  continues,  and  the  diameter  of 
the  appendix  becomes,  in  consequence,  gradually  lessened.  The 
blood-vessel  walls  are  often  thickened,  and  at  times  there  is  inter- 


Pathology  1 1 1 

stitial  hyperplasia  of  the  nerves,  especially  of  those  of  the  meso- 
appendix.  There  may  also  be  some  proliferation  of  the  endothelium 
of  the  blood-vessels. 


OBLITERATING  APPENDICITIS. 

By  obliterative  or  obliterating  appendicitis  is  understood  a 
variety  of  interstitial  inflammation  of  the  appendix  attended  by 
or  leading  to  obliteration  of  its  lumen.  We  have  found  2  per  cent, 
of  the  cases  of  chronic  interstitial  appendicitis  to  be  of  this 
subvariety. 

Macroscopy.— Upon  naked  eye  examination  such  appendices, 
as  a  rule,  do  not  differ  materially  from  those  described  under  the 
heading  Chronic  Interstitial  Appendicitis.  In  some  instances, 
however,  the  region  of  the  obliteration  of  the  lumen  is  made  evident 
by  a  marked  thinning  of  the  appendix,  which  may  be  reduced  to 
one-half  or  less  of  its  original  size.  Exceptionally,  it  may  be 
reduced  to  a  mere  filament;  and  if  but  a  portion  be  so  affected, 
this  presents  a  marked  contrast  to  the  remaining  portion,  which  may 
be  normal  in  thickness,  or  even  somewhat  increased,  as  a  conse- 
quence of  h)rperplasia  of  the  muscular  coats.  Upon  endeavoring 
to  incise  the  organ — that  is,  to  open  its  lumen  lengthwise — the 
obstruction  or  obliteration  of  the  lumen  is  encountered.  This  may 
be  situated  anywhere  along  the  course  of  the  appendix,  and,  depend- 
ing upon  the  stage  of  the  process,  there  may  be  friable  bands  of 
adhesions  or  an  impervious  band  of  dense  cicatricial  connective 
tissue.  Indeed,  the  whole  appendix  may  be  converted  into  such 
an  impervious  band  of  connective  tissue  by  obliteration  of  the 
entire  lumen.  Under  such  circumstances,  of  course,  subsequent 
attacks  of  appendicitis  are  rendered  impossible:  that  is,  a  so-called 
natural  cure  has  resulted.  Such  an  event  is  of  no  great  rarity. 
Usually,  the  obliteration  is  limited  to  a  portion  of  the  organ,  which 
may  be  the  tip,  the  distal  third,  a  half,  or  more.  At  times,  as 
already  indicated,  the  obliteration  may  affect  a  portion  of  the 
appendix  at  a  distance  from  the  tip,  and  the  latter,  if  its  mucous 
membrane  be  preserved  and  functional,  may  subsequently  become 
the  seat  of  cystic  dilatation.  Appendices  the  seat  of  obliteration 
of  the  lumen  are  commonly  embedded  in  a  dense  mass  of  fibrous 


112  Appendicitis 

adhesions,  which,  by  contracting,  tend  to  hasten  the  process  of 
obliteration.  Even  if  complete  obliteration  occurs,  these  adhesions, 
which  remain,  sometimes  give  rise  to  disastrous  intestinal  and 
other  complications. 

Senn,  who  has  directed  particular  attention  to  the  obliterating 
variety  of  appendicitis,  speaks  of  varying  degrees  of  contraction 
of  the  lumen  of  the  appendix  that  he  has  encountered,  and  that 
differ  in  extent  from  slight  stenosis  to  complete  obliteration;  and 
these  cases  he  includes  in  his  category  of  obliterative  or  obliterating 
appendicitis.  It  seems  to  me,  however,  that  this  is  an  incorrect 
interpretation  of  the  pathological  conditions,  and  that  it  is  much 
wiser  to  limit  the  designation  obliterative  appendicitis  to  those 
cases  in  which  an  actual  obliteration  of  the  lumen  occurs,  and  to 
exclude  those  cases  developing  merely  a  constriction — a  stenosis 
of  the  lumen.  These  are  essentially  different  pathologically. 
In  the  latter  the  lumen  is  preserved,  though  it  tends  to  become 
progressively  smaller,  and  is  always  less  than  normal;  it  may  be 
lined  in  part  by  epithelium,  or  in  great  part  by  cicatricial  connective 
tissue,  but  there  is  still  some  opening  through  the  stricture,  just  as 
there  is  through  a  stricture  of  the  urethra,  which  is  hardly.spoken 
of  as  an  obliterative  urethritis.  In  the  case  of  true  obliterative 
appendicitis,  however,  the  opposed  surfaces  of  the  lumen  have 
become  firmly  united  to  each  other,  and  the  obliterating  band  is 
absolutely  impervious.  Were  the  designation  obliterative  appen- 
dicitis employed  in  all  cases  in  which  the  constriction  of  the  lumen 
becomes  marked,  many  of  the  cases  that  I  have  included  in  the 
category  of  simple  chronic  interstitial  appendicitis  would  necessarily 
be  classed  as  obliterative — a  classification  impossible  of  justification. 

Microscopy. — ^The  microscopical  appearances  of  the  appen- 
dices in  cases  of  obliterative  appendicitis  do  not  differ  from  those 
described  in  connection  with  chronic  interstitial  appendicitis; 
they  are  merely  more  extensive.  In  extreme  cases  microscopical 
examination  may  reveal  nothing  but  dense  cicatricial  connective 
tissue  and  a  few  muscle  fibres,  especially  in  the  impervious  bands 
mentioned. 

There  are  several  particular  forms  of  chronic  disease  of  the 
appendix  that  may  be  attended  by  ulceration  and  that  demand 


Pathology  113 

special  consideration.  Of  these,  the  most  important  are  tuber- 
culosis and  actinomycosis. 

Tuberculosis  of  the  appendix  may  be  primary  or  secondary, 
miliary  or  caseous.  Primary  tuberculosis  of  the  appendix  must  be 
accounted  among  the  greatest  of  rarities,  and  it  may  be  doubted 
whether  any  well-authenticated  case  of  primary  tuberculosis  of 
the  appendix  has  yet  been  recorded.  Even  in  the  event  of  detecting 
tuberculosis  of  the  appendix  alone,  particularly  at  operation,  it  is 
hardly  possible  to  assert  with  certainty  that  tuberculosis  does  not 
exist  elsewhere  in  the  body;  that  the  condition  is  primary  in  the 
appendix.  Of  the  occurrence  of  tuberculosis  of  the  appendix  in 
association  with,  or  secondary  to,  tuberculous  lesions  elsewhere  in 
the  body  a  great  number  of  instances  have  been  observed.  There 
are,  however,  no  trustworthy  statistics  of  sufficient  magnitude  upon 
which  to  base  an  opinion  as  to  the  frequency  of  their  occurrence. 
Fenwick  and  Dodwell,  who  reported  the  records  of  the  necropsies 
performed  upon  2000  subjects  dead  of  tuberculosis  in  the  Brompton 
Hospital  for  Consumption,  found  that  the  intestine  was  the  seat 
of  ulceration  in  500  (56.6  per  cent.)  out  of  887,  cases.  In  85  per 
cent,  of  these  cases  the  ileo-caecal  region  was  involved;  in  9.6  per 
cent,  it  was  the  only  portion  of  the  intestine  that  showed  evidence 
of  disease.  From  this  region  the  frequency  of  implication  diminished 
in  both  directions.  Thus,  the  jejunum  was  involved  in  28  per  cent, 
of  the  cases;  the  duodenum,  in  3.4  per  cent.;  the  ascending  colon 
in  51.4  per  cent. ;  the  transverse  colon,  in  30.6  per  cent.;  the  descend- 
ing colon,  in  21  per  cent.;  the  sigmoid  flexure,  in  13.5  per  cent.; 
and  the  rectum,  in  14. i  per  cent.  It  was  quite  exceptional  to  find 
the  appendix  uninvolved  when  there  was  disease  of  the  ileo-caecal 
region;  in  17  of  the  cases  the  appendix  was  the  only  portion  of  the 
intestinal  tract  that  presented  ulceration.  Whether  or  not  this 
ulceration  was  tuberculous  was  not  definitely  determined. 

Upon  macroscopical  examination  tuberculosis  of  the  appendix 
is  likely  to  elude  observation  in  many  cases.  The  lesions  may 
not  differ  materially  from  those  of  simple  catarrhal  inflammation 
or  ulceration  of  the  appendix.  On  the  other  hand,  the  entire 
mucous  membrane  may  have  become  converted  into  a  discolored 
caseous  mass,  with  more  or  less  extensive  ulceration.  At  times 
the  nature  of  the  affection  may  be  recognized  by  the  detection  of 
8 


114  Appendicitis 

minute  grayish  tubercles  in  the  floor  of  the  ulcer,  or  similar  tubercles 
may  reveal  themselves  beneath  the  peritoneal  coat  of  the  organ. 
If  there  be  extensive  tuberculous  disease  elsewhere  in  the  body, 
of  course,  the  tuberculous  character  of  the  lesions  of  the  appendix 
is  more  likely  to  be  recognized.  If  the  disease  be  of  the  miliary 
variety,  it  should  not  escape  detection;  it  is  usually  associated  with 
similar  disease  of  other  intra-abdominal  organs  or  tissues,  particu- 
larly the  peritoneum.  Tuberculosis  of  the  appendix  does  not 
manifest  any  very  marked  tendency  to  perforation,  though  such 
eventuality  may  occur.  In  almost  all  cases  there  is  associated  a 
more  or  less  circumscribed  tuberculosis  of  the  peritoneum.  The 
lesions  are  eminently  chronic,  and  tend  to  the  formation  of  fistulas. 

Upon  microscopical  examination  the  well-known  lesions  of 
tuberculosis  are  detected.  There  are  more  or  less  extensive  forma- 
tion of  epithelioid  cells,  giant  cells,  and  round-cell  infiltration,  with 
a  varying  amount  of  caseation  and  partial  or  complete  degeneration 
of  the  cellular  exudate.  The  lesions  are  prone  to  involve  the 
lymphoid  follicles  and  to  spread  along  the  submucous  coat,  possibly 
involving  other  tissues;  but  histologically  they  do  not  differ  from 
similar  lesions  in  other  portions  of  the  body.  With  appropriate 
staining  procedures  tubercle  bacilli  may  be  detected. 

Actinomycosis  of  the  appendix  is  a  rare  condition  due  to  the 
pathogenetic  activity  of  Streptothrix  actinomyces,  or  ray  fungus. 
Actinomyces  in  man  is  itself  a  rather  rare  condition,  and  up  to  1899 
Ruhrah  was  able  to  collect  from  the  literature  but  70  cases  reported 
in  this  country.  Of  these,  the  appendix  was  affected  in  5.  Hinglais, 
who  has  studied  the  appendico-caecal  form,  found  it  in  60  out  of 
100  cases  of  the  abdominal  form.  Grill,  in  reporting  four  personal 
observations  of  the  abdominal  form  of  the  disease,  was  able  to  find 
107  other  cases  in  the  literature.  In  40  of  the  latter  the  portal  of 
entry  of  the  actinomyces  was  definitely  made  out,  and  was  as  follows: 
The  appendico-caecal  region  in  19;  the  colon  in  8;  the  rectum  in  7; 
and  other  portions  of  the  intestinal  tract  (jejunum,  duodenum,  etc.) 
in  6.  In  26  of  the  cases  the  process  was  perityphlitic  and  para- 
typhljtic,  but  no  portal  of  entry  could  be  definitely  located;  in  7,  the 
process  was  peri-rectal;  and  in  36,  the  portal  of  entry  was  entirely 
indeterminate.  Since  the  last  edition  of  this  book  but  few  addi- 
tional cases  of  actinomycosis  of  the  appendix  have  been  reported. 


Pathology 


Hi 


To  the  total  of  39  cases  there  tabulated  may  be  added  one  case  by 
Rowntree,  seven  by  Waring,  and  two  by  Murphy,  making  a  total  of 
49  cases  up  to  the  present  time. 

Actinomycosis  of  the  appendix  may  be  the  result  of  direct 
infection — ^through  the  intestinal  tract;  of  indirect  infection,  or 
extension  from  the  thoracic  cavity — through  the  diaphragm,  behind 
the  peritoneum,  or  through  the  abdominal  muscles;  or  it  may  be  the 
consequence  of  metastasis.  According  to  Hinglais,  the  affection 
may  be  divided  into  four  stages;  (i)  The  period  of  visceral  symp- 
toms, which  may  last  from  a  few  days  to  several  months;  (2)  the  period 
of  tumor,  which  varies  much  in  duration,  and  during  which  frequent 
remissions  may  occur;  (3)  the  period  of  fistula,  during  which  the 
disease  may  extend  to  other  tissues,  such  as  the  lumbar  region,  the 
psoas  muscle,  the  hip-joint,  the  space  of  Retzius,  etc.,  and  during 
which  extensive  abscess  formation,  with  fistula,  which  is  likely  to  be 
multiple,  may  develop;  (4)  the  period  of  reparation,  during  which 
the  affection  may  heal  spontaneously  or  as  a  consequence  of  surgical 
procedures.  On  the  other  hand,  the  disease  may  persist  indefinitely 
and  may  finally  terminate  fatally. 

It  is  agreed  by  many  writers  that  it  is  most  likely  that  the  affection 
in  these  cases  is  primary  in  the  appendix;  that  the  fungus  is  carried 
to  the  appendix  by  some  grain  or  fragment  of  corn  or  barley;  and 
that  this  lodges  in  the  appendix,  wherein  the  actinomyces  pro- 
liferates. Waring,  on  the  other  hand,  holds  that  the  appendix  is 
not  always  the  primary  seat  of  the  disease,  but  that  actinomycosis 
like  tuberculosis  is  more  frequently  primary  in  the  caecum.  Czerny 
and  Haeddeus,  from  a  careful  study  of  their  cases,  conclude  that 
there  first  occurs  an  infection  of  the  appendicular  mucous  membrane, 
which  becomes  necrotic  and  gives  rise  to  the  formation  of  an  ulcer. 
This  permits  of  ready  access  of  the  actinomyces  to  the  submucosa, 
wherein  it  further  proliferates,  and,  meeting  with  slight  resistance, 
extends  in  various  directions.  In  one  of  their  cases  the  mucous 
membrane  did  not  appear  ulcerated,  and  this  fact  is  explained  by 
supposing  that,  after  the  formation  of  the  ulceration  and  the  infection 
of  the  submucosa,  reparation  of  the  mucosa  occurred,  and  that  the 
necrotic  mucous  membrane  was  replaced  by  cicatricial  connective 
tissues.  These  suppositions  are  confirmed  by  the  absence  of  Lieber- 
kiihn's  glands  in  the  mucous  membrane.     Infection  having  occurred, 


ii6  Appendicitis 

suppuration,  with  the  formation  of  fistulas,  may  supervene,  or  there 
may  result  the  development  of  thick,  indurative  connective  tissue. 
This  dififers  from  ordinary  cicatricial  connective  tissue  in  that  it 
contains  small  foci  of  pus,  vv^hich  may  be  absorbed  if  the  fungus  be 
absent.  If  the  fungus  be  present,  on  the  other  hand,  there  may 
ensue  further  extension  of  the  disease.  In  the  peri-appendicular 
pus  the  characteristic  grayish  nodules  may  be  detected.  Upon 
microscopical  examination  these  are  found  to  be  composed  in 
whole  or  in  part  of  Streptothrix  actinomyces. 

It  has  been  pointed  out  by  Earth,  Partsch,  and  other  observers 
that  in  those  cases  in  which  there  occurs  symbiosis,  with  the  ordinary 
pyogenic  cocci,  the  actinomycotic  nature  of  the  affection  is  likely 
to  be  non-apparent.  It  is  only  later,  when,  as  a  consequence  of 
extension  or  metastasis,  the  disease  develops  in  another  portion  of 
the  body,  that  the  true  nature  of  the  original  infection  is  recognized. 
Probably  because  of  this,  and  because  some  unsuspected  cases  have 
been  cured  at  the  primary  seat  of  the  disease,  actinomycosis  of  the 
appendix  seems  more  rare  than  it  really  is. 

Tumors  of  the  Appendix  may  be  primary  or  secondary,  benign 
or  malignant.  Primary  tumors,  both  clinically  and  histologically 
benign,  are  very  uncommon.  Lafforgue,  in  1893,  reported  6  cases 
in  his  series  of  17  tumors  of  the  appendix  including  one  lipoma, 
one  myoma,  two  lymph-adenoma,  and  two  hydatid  cysts.  From 
time  to  time  since  then  an  occasional  report  is  made  of  such  be- 
nign growths  arising  in  the  appendix.  Kelly,  Schrumpf,  Pressly 
and  Oberndorfer  have  reported  cases  of  appendiceal  polyps. 
Kelly,  Monnier  and  Aboulker  have  observed  plain  myomata, 
while  the  former  has  described  a  fibromyoma  that  was  calcified. 

Personally,  I  have  encountered  two  cases  of  fibromyoma  of  the 
appendix.  One  was  from  a  patient  the  subject  also  of  fibromyomas 
of  the  uterus,  and  both  organs  were  removed  at  the  same  operation.* 
The  appendix  presented  two  fibroid  growths,  each  of  which  was 
spheroid  in  shape  and  about  five  millimetres  in  diameter.  One  was 
situated  at  the  mid-point  of  the  appendix,  opposite  the  attachment 
of  the  mesentery;  the  other  toward  the  tip  of  the  organ,  within  the 
mesenteric  attachment.     They  projected  somewhat  from  the  surface 

'  This  case  has  been  reported  by  Dr.  Deaver  in  the  Transactions  of  the  Academy 
of  Surgery  of  Philadelphia,  vol.  i,  1899,  p.  23. 


Pathology  117 

of  the  appendix,  and  each  was  well  circumscribed,  surrounded  by  a 
rather  dense  capsule,  and  was  firm  to  the  touch.  On  section  they 
were  whitish  and  glistening,  and  revealed  a  fibrillar  structure.  One 
was  much  harded  than  the  other — being  of  almost  stony  hardness — 
and  cut  with  a  grating  sensation.  The  wall  of  the  appendix  else- 
where was  much  thickened;  the  lumen  much  constricted.  The 
mucous  membrane  appeared  smooth  and  atrophic.  On  micro- 
scopical examination  the  lesions  of  moderate  interstitial  appendicitis 
(as  already  detailed),  with  considerable  thickening  of  the  walls  of 
the  blood-vessels  were  detected.  The  tumors  consisted  of  bundles 
of  dense  fibrous  connective  tissue  that  coursed  in  various  directions 
and  intertwined  among  themselves,  and  interspersed  between  which 
there  was  a  small  amount  of  unstriped  muscle  fibres.  The  connec- 
tive tissue  contained  relatively  few  nuclei  and  an  abundance  of 
intercellular  substance.  The  blood  supply  was  moderately  good, 
but  the  walls  of  the  blood-vessels  were  thickened.  The  growth 
opposite  the  attachment  of  the  mesentery  contained  a  considerable 
amount  of  calcareous  infiltration.  The  second  specimen  was  much 
like  the  first.  There  was,  however,  but  a  single  nodule,  which 
contained  no  calcareous  infiltration.  In  other  respects  the  resem- 
blance was  marked.  * 

Carcinomata. — At  the  time  of  the  first  editing  of  this  work 
primary  malignant  tumors  of  the  appendix  were  very  rare.  As 
mentioned  above,  Lafforgue  in  1893  found  but  nine  cases  in  the 
literature  to  that  date.  At  the  second  editing  Dr.  A.  O.  J.  Kelly 
was  able  to  collect  but  twenty  authentic  cases,  but  stimulated  by 
these  interesting  observations  more  systematic  microscopic  examina- 
tion of  appendices  removed  at  operation  has  been  followed  by  a 
steady  increase  in  finding  of  malignant  new  growths  in  the  appendix, 
so  that  in  1905  at  the  third  editing  of  this  work  Dr.  Kelly  was  able  to 
report   on  forty-five  cases   of  malignant   appendiceal   neoplasms. 

Since  1905  there  has  been  a  continued  increase  in  the  number  of 
cases  reported,  and  in  1908  Mc Williams  brought  the  total  up  to 
105  cases,  and  in  the  same  year  Harte  collected  120  cases,  and 
though  a  thorough  compilation  since  that  date  is  not  at  hand  but  a 
cursory  review  of  the  literature  is  needed  to  assure  one  that  the 
number  is  still  rapidly  increasing,  and  it  can  therefore  be  readily 
seen  that  this  condition  ceases  to  be  a  rarity. 


ii8  Appendicitis 

The  ability  to  collect  as  large  a  number  as  is  possible  at  present 
naturally  leads  to  analysis  and  study  of  this  important  problem  of 
to-day  and  we  are  now  able  to  discuss  the  question  from  a  sufficient 
series  of  careful  observations  to  draw  some  definite  conclusions  as  to 
their  occurrence  and  characteristics  of  growth,  to  point  out  their 
peculiar  benignancy,  to  describe  their  typical  histological  malignancy 
and  possibly  to  throw  some  light  on  their  origin.  It  is  gratifying  at 
this  time  to  be  able  to  remark  on  the  active  work  along  these  lines 
that  has  been  borne  by  American  investigators  and  it  is  from  them 
that  the  early  systematic  microscopic  examinations  of  appendices 
removed  at  operation  were  rewarded  by  the  rather  frequent  finding  of 
neoplastic  growths,  and  the  literature  upon  the  subject  is  mostly 
to  be  found  in  the  English  language. 

The  age  of  the  patients  presenting  carcinoma  of  the  appendix  is 
one  of  the  most  interesting  features,  for  the  usual  rule  of  malignancy 
is  broken  and  we  find  the  time  of  occurrence  far  below  the  "cancer 
age"  in  an  overwhelming  majority  of  cases.  No  less  than  65 
(54  per  cent.)  of  the  120  cases  reported  by  Harte  occurred  before  the 
age  of  thirty  years,  while  60  per  cent,  of  the  105  cases  collected  by 
McWilliams  were  discovered  before  that  age,  and  again,  in  Harte's 
series  104  of  the  120  cases  were  found  before  the  end  of  the  fifth 
decade,  while  Oberndorfer  says  that  70  per  cent,  occur  before  the 
end  of  the  fourth  decade.  The  average  age  of  occurrence  has  been 
put  by  MacCarty  and  McGrath  as  thirty  years.  Vassmer  put  it  at 
35.3  years,  and  Milner  at  twenty  seven  and  one-half  years.  The 
former  reports  a  case  occurring  in  a  child  of  five  years,  Oberndorfer 
discovered  a  malignant  appendiceal  growth  in  a  child  of  seven 
years,  while  Day  and  Rhea  report  a  case  at  nine  years  of  age  and 
there  are  numerous  other  observations  reporting  cases  before  the 
age  of  puberty.  That  practically  all  these  cases  were  diagnosed 
and  operated  upon  for  appendicitis  is  of  course  recognized  and  the 
association  of  inflammation  with  the  presence  of  carcinoma  (later 
to  be  discussed)  is  also  marked.  So  that  it  is  to  be  expected  that 
during  the  years  of  life  when  operations  for  inflammatory  conditions 
of  this  organ  are  most  frequent  that  the  greater  number  of  cases  of 
early  carcinoma  originating  in  the  appendix  should  be  found,  and 
the  condition  simply  disclosed  by  operation.  One  means  of  ex- 
plaining this  early  occurrence  is  in  the  type  of  cell  forming  the 


Pathology  119 

carcinoma.  Warthin  is  of  the  opinion  that  the  vast  majority  of 
these  growths  are  of  the  spheroidal  or  basal  cell  type  of  carcinoma 
and  in  his  statistics  shows  that  the  average  age  in  the  spheroidal  cell 
carcinoma  was  but  twenty-four  years,  while  in  the  columnar  cell 
type  it  was  about  fifty  years  of  age  which  more  nearly  corresponds 
to  the  age  at  which  primary  carcinoma  of  the  intestine  (the  major- 
ity here  being  of  the  columnar  cell  type)  occurs.  Moreover,  this 
prevailing  variety  of  spheroidal  cell  carcinoma  is  less  prone  to  give 
malignant  metastasis,  a  feature  of  marked  significance  in  these 
appendiceal  tumors. 

The  association  of  appendicitis  with  these  neoplastic  growths 
and  the  frequent,  simultaneous  occurrence  of  both  conditions  in 
this  organ  has  been  recognized  and  dwelt  upon  by  all  writers  and 
the  question  naturally  arises,  which  of  the  two  conditions  is  the 
primary  one.  As  we  now  study  the  cases  it  appears  that  nearly  all 
have  presented  symptoms  sufficiently  alarming  to  warrant  opera- 
tion under  the  diagnosis  of  chronic  appendicitis,  and  even  in  the 
cases  where  acute  inflammation  has  been  found  in  association  with 
carcinoma  the  probability  is  that  this  acute  condition  has  been 
grafted  on  an  old  case  of  chronic  inflammation  of  the  appendix. 
But  if  ultimately  appendicitis  is  proven  the  primum  movens  in  the 
development  of  appendiceal  carcinoma,  we  cannot  at  present  deny 
the  possibility  that  the  reverse  may  be  true. 

The  histological  picture  of  carcinoma  of  the  appendix  when  it 
arises,  as  it  frequently  does,  in  connection  with  obliterative  appen- 
dicitis lends  attractive  support  to  Ribbert's  theory  of  the  origin  of 
malignant  growths;  that  tumors  arise  from  a  partial  or  complete 
separation  of  cells,  or  groups  of  cells,  from  their  organic  continuity, 
in  other  words  from  a  mechanical  isolation  which  as  we  know  finds 
its  chief  cause  for  their  detachment  in  chronic  connective  tissue  in- 
flammation. We  cannot,  however,  eliminate  the  possibility  of 
malignant  change  in  the  normally  situated  epithelium  under  the  con- 
ditions of  chronic  irritation  that  exists  so  frequently  in  chronic 
appendicitis. 

Maschowitz  states  that  66  per  cent,  of  the  cases  studied  by  him 
were  preceded  by  symptoms  of  acute  inflammation  of  the  appendix 
and  in  McWflliam's  statistics  63  per  cent,  had  had  associated  inflam- 
matory changes. 


I20  Appendicitis 

As  it  has  been  shown  to  be  the  rule  to  find  chronic  inflammatory 
changes  associated  with  the  new  growths,  so  also  a  large  number  of 
these  cases  show  definite  obstruction  of  the  lumen  and  in  many  cases 
complete  obliteration  of  the  lumen  had  taken  place  proximal  to  the 
neoplasm.  This  also  must  be  taken  as  a  possible  astiological 
factor  and  has  so  been  dwelt  upon  by  many  authors.  Mac C arty 
and  McGrath  find  carcinoma  present  in  1.9  per  cent,  (or  once  in 
every  fifty-three  cases),  of  partially  or  totally  obliterated  appendices 
removed  at  operation. 

The  location  of  the  growth  is  apparently  in  close  relationship 
to  the  aforementioned  obstruction  of  the  lumen  and  the  predilection 
of  the  neoplasm  to  occur  in  the  distal  portions  of  the  organ  is  quite 
marked.  MacCarty  and  McGrath  report  90  per  cent,  as  being 
"in  the  tip"  of  the  organ,  while  76  per  cent,  of  Mc Williams'  cases 
are  stated  to  have  occurred  distal  to  the  middle  of  the  appendix. 
The  prevalence  of  the  occurrence  of  malignant  changes  in  the  distal 
portion  has  also  a  pathological  significance,  though  probably  closely 
allied  to  the  associated  inflammatory  changes,  yet  that  this  occur- 
rence of  the  neoplasm  in  the  distal  portion,  whatever  it  may  be  due 
to,  has  some  important  bearing  on  the  late  formation  of  metastasis 
must  also  be  considered. 

A  unique  feature  is  the  small  size  of  the  growth  even  in  cases 
found  at  autopsy  in  elderly  people.  Rarely  is  the  tumor  described 
as  greater  than  a  walnut  in  extent  and  this  of  course  is  in  just 
relationship  to  the  known  benignancy  later  to  be  discussed.  Of 
course  we  must  remember  that  in  dealing  with  as  small  an  organ  as 
the  appendix  that  large  growths  may  have  occurred,  and  as  such 
have  given  rise  to  metastasis,  the  primary  growth  itself  infiltrating 
the  caecal  wall,  and  have  as  a  result  been  classified  as  tumors  of  the 
caecum  and  their  appendiceal  origin  has  been  completely  hidden,  but 
nevertheless  the  rule  has  been  to  find  only  a  small  nodule  which  on 
microscopic  examination  reveals  the  picture  of  a  malignant  epithelial 
neoplasm. 

There  is  a  slight  predominance  of  occurrence  in  the  female  sex, 
and  though  the  anatomical  relations  are  identical  in  the  male  and 
female  with  the  exception  of  an  occasional  appendiculo-ovarian  liga- 
ment in  the  latter,  this  increased  occurrence  is  sufficiently  marked 
to  be  worthy  of  comment.     Fifty-seven  per  cent,  of  Mc  Williams' 


Pathology 


121 


105  cases  occurred  in  women  and  69.4  per  cent,  in  Harte's  series 
were  of  the  female  sex. 

The  incidence  of  carcinoma  of  the  appendix  will  largely  de- 
pend upon  the  thorough  microscopic  study  of  all  appendices 
removed,  for,  as  has  been  said  above,  practically  all  of  the  cases 
have  been  operated  upon  under  the  diagnosis  of  appendicitis  and 
only  subsequent  close  investigation,  aided  by  microscopic  study, 
has  demonstrated  the  presence  of  a  neoplastic  growth.  Mac- 
Carty  and  McGrath  found  the  incidence  to  be  0.44  per  cent,  and  in 
their  series  of  twenty- two  cases  in  5000  appendectomies  this  meant 
once  in  every  227  diseased  appendices.  Mc Williams  has  found  it 
twenty-six  t'mes  in  6505  appendectomies,  that  is  0.4  per  cent.,  or 
once  in  every  250  cases.  Baldauf  claims  that  i  per  cent,  of  all 
inflamed  appendices  will  be  found  to  show  malignant  changes,  while 
Harte  says  it  is  present  in  one-third  of  i  to  i  per  cent,  of  the  cases. 
In  the  previous  edition  of  this  treatise  the  percentage  was  placed  at 
0.2  per  cent,  and  to  date  (Sept.  i,  1912)  in  the  service  of  Dr.  Deaver 
at  the  German  Hospital,  Philadelphia,  6327  appendices  have  been 
examined  microscopically  and  sixteen  instances  of  malignant 
neoplasm  have  been  found  giving  the  percentage  as  0.25  per  cent.,  or 
once  in  every  395  cases. 

The  clinical  benignancy  is  a  striking  feature  of  carcinoma  of 
the  appendix.  Milner  (1909)  goes  so  far  as  to  say  that  a  true 
clinically  outspoken  carcinoma  of  the  appendix  has  not  been  de- 
scribed. That  the  majority  of  these  cases  are  completely  cured  by 
appendectomy  alone  and  that  recurrence  is  a  rare  condition  cannot 
be  denied.  It  is  true  that,  possibly  excepting  the  cases  of  Voeckler 
and  of  Lejars,  recurrence  has  been  most  rare  and  the  histological 
picture  shows  no  trace  of  a  mahgn  character,  such  a  destruction  of 
tissue,  numerous  mitotic  figures  and  widespread  invasive  power 
while  the  cells  themselves  are  usually  small,  show  many  degenerative 
changes  and  necrosis,  presenting  a  picture  which  in  its  entirety 
suggests  a  tissue  of  lowered  vitality.  That  these  facts  alone  would 
also  exclude  the  probability  that  these  growths  would  attain  any 
appreciable  size  during  the  life  of  their  carriers,  even  if  permitted 
to  remain  a  long  time  in  the  body,  coincides  with  the  observations  of 
the  cases. 

The  histologically  malignant  character  of  these  tumors  has 


122  Appendicitis 

been  attested  to  by  all  observers.  x\s  has  before  been  mentioned  the 
type  of  tumor  cells  follows  in  the  main  two  varieties. 

First,  the  most  frequently  found  form  is  the  spheroidal-cell 
carcinoma,  or  the  so-called  basal-cell  cancer,  which  is  recognized 
as  a  type  characterized  by  its  relatively  slow  growth,  the  absence  of 
early  metastasis  and  the  lack  of  recurrence  after  operative  removal. 
In  this  type  the  individual  cells  are  epithelial  in  appearance,  poly- 
hedral or  irregular  in  shape,  possibly  small,  round  or  quite  flattened 
where  the  cluster  of  cells  draws  to  a  point,  their  nuclei  are  vesicular 
and  stain  well,  they  occur  in  nests  devoid  of  alveolar  formation  and 
with  a  marked  tendency  toward  stroma  development.  Moreover 
this  type  as  shown  by  Warthin  is  apt  to  be  found  in  early  life  and  is 
quite  similar  to  the  so-called  basal  carcinoma  of  the  skin.  The  second 
type  is  that  typical  of  intestinal  carcinoma  as  it  is  seen  elsewhere  in 
the  abdominal  cavity,  formed  of  columnar  cells  with  the  formation 
of  a  more  or  less  distinct  lumen.  We  see  the  cells  arranged  in  nests, 
they  are  large  and  ovoid,  others  are  elongated  and  narrow^,  their 
nuclei  are  clear,  vesicular  and  stain  well.  The  stroma  is  relatively 
inconspicuous  as  compared  with  the  masses  of  tumor  cells,  the  latter 
often  seen  as  solid  nests,  the  individual  cells  polyhedral  in  shape 
from  mutual  compression,  they  can  again  be  found  in  double  or 
triple  layers,  and  elsewhere  appear  as  hollow  cylinders  being  com- 
posed of  a  single  layer  of  cells  surrounding  a  clear  lumen. 

The  prevalence  of  the  spheroidal  cell  variety  of  carcinoma  is 
shown  in  the  statistics  of  Rolleston  and  Jones.  Also,  Mc Williams 
finds  it  the  most  frequent  occurring  variety,  being  present  in  38 
per  cent,  of  his  cases.  The  growth  is  usually  located  in  the  mucosa 
and  submucosa  or  penetrating  the  connective  tissue  which  replaces 
these  layers  in  cases  of  obliterative  appendicitis  spreading  its  par- 
enchyma cells  as  far  as  the  meso-appendix  but  rarely  giving  other 
signs  of  malignancy  characteristic  of  intestinal  cancer,  i.  £■.,  metastases 
to  the  surrounding  peritoneal  surfaces  in  the  vicinity  of  the  growth, 
involvement  of  the  neighboring  glands  of  the  mesentery  or  recur- 
rence after  operation. 

When  proliferation  does  not  proceed  from  the  obliterated  areas, 
the  submucosa  appears  to  be  the  point  of  origin  for  infiltration, 
and  spreading  from  thence  the  cells  are  found  in  the  lymph  spaces 
of  the  muscle  layer,  frequently  in  the  subserosa  of  the  appendix 


Pathology  123 

and  even  the  meso-appendix.  Moreover  these  proHferations  have 
no  connection  or  traceable  continuity  with  the  glands  or  with  the 
epithelium  of  the  mucous  membrane. 

Metastases  have  been  proved  to  occur  in  the  cases  of  LeConte, 
A.  T.  Cabot,  Beger,  Harte  (Case  VIII),  Whipham,  Edington, 
Weir  and  White.  While  the  cases  reported  by  Voeckler  and  by 
Lejars  had  undoubted  recurrences. 

The  theory  has  been  advanced  by  Milner  and  others  that 
these  growths  are  endothelioma  rather  than  carcinoma.  The 
weight  of  opinion  and  evidence,  however,  are  in  favor  of  the  belief 
that  the  constituent  cells  are  of  epithelial  origin  though  an  ex- 
planation of  the  peculiar  benignancy  of  these  growths  as  contrasted 
with  other  epithelial  neoplasms  is  not  yet  forthcoming. 

In  1909  Milner  published  an  article  in  which  he  cast  doubt  upon 
the  accuracy  of  the  diagnosis  of  carcinoma  of  the  appendix  in 
practically  all  previously  reported  cases,  especially  in  those  occurring 
in  comparatively  young  individuals.  He  attempted  to  prove  that 
these  neoplasms  were  of  inflammatory  origin  and  the  products  of 
hyperplastic  chronic  lymphangitis  proceeding  from  proliferation 
of  the  endothelium  of  the  lymph  spaces,  or  else  from  pathological 
depressions  of  the  mucous  membrane.  He  based  this  on  first,  the 
apparent  benign  nature  of  the  tumors  and  their  frequent  occurrence 
in  the  young,  and  secondly  on  the  variations  of  morphology  of  the 
tumor  parenchyma  from  the  cylindrical  cell  epithelium  of  the  neigh- 
boring intestines  and  its  glands.  He  attempts  to  strengthen  his 
position  by  the  work  of  Orth  and  Borst  on  chronic  lymph  vessel 
inflammation  associated  with  proliferation  of  the  endothelium,  and 
states  that  he  has  seen  proliferation  in  actinomycosis  that  was 
histologically  identical  with  carcinoma. 

This  work  of  Milner  has  stirred  up  quite  a  quantity  of  comment, 
but  no  one  with  the  exception  of  Neugebauer,  seems  ready  to  accept 
his  views.  Sternberg,  Bertel,  Goetjes,  Burkhardt,  and  Dietrich 
all  hold  that  we  cannot  make  a  distinction,  the  latter  saying  that 
"we  have  in  these  small  cell  tumors  of  the  appendix,  associated 
with  chronic  and  acute  inflammation  a  characteristic  tumor  forma- 
tion which  anatomically  must  be  recognized  as  undifferentiable 
from  carcinoma."  Voeckler  says,  after  a  thorough  dissertation, 
"I  must  nevertheless  contend,  contrary  to  the  views  of  Milner,  that 


124  Appendicitis 

these  cases  represent  a  true  carcinoma,"  while  Oberndorfer  dismisses 
the  subject  with  the  remark  that,  "we  are  dealing  with  histological 
carcinoma,  but  biologically  benign."  In  the  study  of  the  cases  at 
the  German  Hospital  we  have  been  able  to  agree  with  the  hypothesis 
of  Milner  in  only  one  instance  as  to  the  origin  of  the  new  growth 
from  the  lymph  endothelium.  In  this  case,  indeed,  it  is  questionable 
whether  we  are  dealing  with  an  endothelioma  rather  than  a  simple 
hyperplastic  lymphangitis.  The  remainder  of  the  cases  show  in 
every  instance  what  we  considered  to  be  evidences  of  derivation 
from  epithelial  cells. 

It  is  noteworthy  that  with  proper  staining  methods  the  products 
of  secretion,  or  of  degenerations  of  the  cells  themselves  could  be 
demonstrated  to  be  mucin,  a  feature  we  have  never  observed  in 
connection  with  endothelioma,  and  we  feel  that  here  we  have  to  do 
with  an  epithelial  tumor,  which  in  form  and  arrangement  of  its  cells, 
also  in  the  manner  of  its  proliferation  has  the  character  of  a  car- 
cinoma, though  the  proof  is  lacking  for  their  clinical  malignancy 
through  the  formation  of  metastasis  and  the  development  of 
recurrences. 

Sarcoma. — This  type  of  tumor  occurs  as  primary  in  the  appendix 
but  its  rarity  is  shown  by  the  fact  that  to  the  present  but  nine  authen- 
tic cases  have  been  reported  (Wright).  The  growth  is  usually  of 
the  small  round-cell  variety  or  lympho-sarcoma.  There  is  generally 
an  early  involvement  of  the  caecal  wall  and  its  degree  of  malignancy 
is  unaltered.  Sixty-six  per  cent,  of  the  cases  occurred  in  the  male 
sex.  A  recent  case  of  my  own  is  of  sufl&cient  rarity  and  interest  to 
deserve  special  mention. 

The  patient,  P.  H.,  aged  thirty-nine  years,  a  male  of  Russian  extraction,  a 
tailor  by  occupation,  was  admitted  to  the  German  Hospital  April  4,  19 12.  His 
family  and  personal  history  was  unimportant. 

For  two  months  before  admission  he  had  at  times  felt  pain  in  the  right  loin 
of  a  dull  aching  character.  He  asserted  that  he  had  had  pain  on  urination. 
He  was  nervous  and  troubled  with  headache.  His  appetite  and  digestion  were 
good  but  he  was  inclined  to  constipation. 

About  one  month  previously  the  patient  had  discovered  a  lump  in  the  right 
side  of  the  abdomen.  It  had  increased  slowly  in  size.  There  was  no  history 
of  injury  or  loss  of  weight. 

The  examination  revealed  nothing  of  note  except  in  the  right  abdomen  where 
a  rounded  mass  the  size  of  a  large  orange  could  be  grasped  with  ease  and  moved 


Pathology 


125 


upward  beneath  the  ribs,  downward  to  the  brim  of  the  pelvis  and  inward  almost 
to  the  median  line.     It  felt  semi-solid  and  was  not  painful  or  tender. 

The  urine  was  negative  and  examination  for  functional  capacity  by  phenol- 
sulphonephthalein  showed  both  kidneys  to  be  normal.  The  blood  showed 
Hgb.  75  per  cent.;  erythrocytes,  4,250,000;  leucocytes,  12,400  with  normal 
differential  formula 


Fig.  12. — Myxosarcoma  of  Appendix  and  Meso-appendix. 


At  operation,  April  15,  1912,  the  abdomen  was  opened  anteriorly  and  an 
ovoid  mass  found  attached  to  the  tip  of  the  appendix  which  served  as  a  pedicle 
for  the  growth  permitting  a  considerable  range  of  motion.  The  appendix,  and 
with  it  the  tumor,  was  removed  as  in  simple  appendectomy. 


126  Appendicitis 

Pathol(^y. — The  appendix  measures  2.5  cm.  in  length,  is  somewhat 
thickened  and  fibrous  but  uniform  in  calibre.  Its  surface  is  moderately  injected 
but  no  other  gross  abnormality  is  present  in  its  proximal  portion.  The  distal 
end  is  continuous  with  a  globular  mass  measuring  13  X  loX  8.5  cm.  The  appen- 
dix is  inserted  tangentially  gi^ing  the  impression  that  the  mass  had  arisen  on 
the  mesenteric  side  of  the  ap[)endix.  The  growth  is  encapsulated,  smooth, 
soft  and  resilient  and  everywhere  covered  with  peritoneum.  On  section  the 
surface  is  homogeneous,  grayish,  glistening  and  translucent  with  faint 
pinkish   markings   throughout. 

Microscopically  the  tissue  is  seen  to  be  composed  of  stellate  embryonic 
connective-tissue  cells  with  much  delicate  intercellular  fibrilke  and  a  hyaline 
matrix.  The  cells  vary  considerably  in  size  and  are  sometimes  multinucleated. 
Often  the  nuclear  material  is  not  definitely  outlined  but  is  diffused  throughout 
the  cell.  Xo  definite  mitotic  figures  are  seen.  The  vessel  walls  are  delicate, 
consisting  often  of  endothelium  only  supported  by  the  tumor  tissue. 

Microscopic  Diagnosis. — Chronic  interstitial  apjjendicitis,  myxosarcoma 
of  appendix  and  meso-appendix. 


THE  PERITONITIS  AND  ITS  CONSEQUENCES. 

Although  the  dissociation  of  the  lesions  of  the  appendix  from 
those  of  its  serous  covering  (peri- appendicitis)  and  the  peritoneum 
in  general  is  at  most  artificial,  there  are  several  reasons,  not  alone 
of  convenience,  that  render  profitable  the  discussion  of  each  sepa- 
rateh*.  In  the  first  place,  similar  lesions  of  the  appendix,  in  different 
cases,  may  give  rise  to  most  diverse  peritoneal  lesions;  that  is,  there 
is  no  constant  relationship  between  the  lesions  of  the  appendix  and 
those  of  the  peritoneum.  There  can  be  no  question  that  in  certain 
cases  of  appendicitis  the  peritoneum  presents  no  deviations  whatever 
from  the  normal.  These  cases,  however,  are  of  comparative  rarity, 
and  are  almost  exclusively  instances  of  catarrhal  or  mild  inflamma- 
tion. But  not  all  cases  of  catarrhal  appendicitis  are  unaccompanied 
by  inflammation  of  the  peritoneum.  Again,  there  are  still  rarer 
cases  of  fulminating  appendicitis  with  rapid  gangrene,  in  which 
the  diseased  organ  may  be  excised  by  the  surgeon,  or  the  patient 
may  die  before  there  has  been  time  for  the  development  of  perit- 
onitis. Further,  instances  of  chronic  interstitial  appendicitis  with 
ulceration,  unattended  by  eridences  of  implication  of  the  peritoneimi, 
have  been  recorded  by  several  observers,  among  them  Schede  and 
Sonnenburg.     But  these  are  unusual  cases.     Excepting  the  preri- 


Pathology  127 

ously  mentioned  instances,  all  cases  of  appendicitis  are  complicated 
by  peritonitis,  and  it  is  for  this  reason  that  the  designation  appendicu- 
lar peritonitis  is  most  appropriate.  It  is  because  of  the  peritonitis 
to  which  it  gives  rise  that  appendicitis  acquires  the  importance 
that  attaches  to  it. 

The  reasons  for  the  implication  of  the  peritoneum  in  appendicitis 
are  not  difficult  to  find.  The  peritoneal  covering  of  the  appendix 
is.  in  reality,  a  portion  of  the  organ  itself,  and  it  is  readily  conceivable 
that  an  inflammation  that  affects  one  or  more  coats  of  a  tube  such 
as  the  appendix  should,  under  favorable  circumstances,  affect  all. 
That  certain  cases  of  catarrhal  appendicitis  are  unattended  by  perit- 
onitis is  equally  plausible.  In  these  cases  the  operations  of  the 
noxious  agents  provocative  of  the  catarrhal  inflammation  are  confined 
to  the  mucous  membrane,  either  because  of  their  attenuation  or  of 
the  resistance  offered  by  the  other  tissues  to  their  further  progress. 
On  the  other  hand,  the  factors  for  the  ready  dissemination  of  the 
inflammatory  irritants  are  found  in  the  virulence  of  the  bacteria  and 
their  toxins  and  in  the  anatomical  construction  of  the  appendix. 
The  liberal  lymphatic  supply  to  which  Polya  and  Xa\Tatil  have 
directed  attention,  and  to  a  less  extent  the  blood  supply,  must  be 
held  answerable  for  the  conveyance  of  the  irritants  from  one  coat 
to  the  others. 

The  detection  of  bacteria  in  association  with  all  varieties  of 
peritonitis  naturally  led  to  the  inference  that  there  was  some  causal 
relationship  between  the  former  and  the  development  of  the  latter. 
The  demonstration  experimentally  that  peritonitis  follows  the  intro- 
duction into  the  peritoneal  cavity  of  certain  bacteria  confirmed  this 
view.     The  matter,  however,  is  not  so  simple  as  at  first  sight  appears. 

In  marked  contrast  to  the  opinions  entertained  some  years  ago, 
it  has  now  been  repeatedly  demonstrated,  both  experimentally  and 
otherwise,  that  the  peritoneum  is  possessed  of  considerable  powers 
of  resistance  to  the  action  of  all  deleterious  influences.  These 
powers  of  resistance  are  comprised  essentially  in  the  following: 
(i)  The  bactericidal  action  of  the  peritoneal  serum;  (2)  the  great 
resorptive  power  of  the  peritoneum;  (3)  the  marked  tendency 
exhibited  by  the  peritoneum  to  unite,  to  form  adhesions,  and  cause 
circumscription — encapsulation  of  infectious  foci.  The  first,  the 
bactericidal  action  of  the  serum  of  the  peritoneum,  is  probably  of 


128  Appendicitis 

little  importance,  though  it  seems  that  it  should  not  be  entirely 
ignored.  The  second,  the  great  resorptive  power  of  the  peritoneum, 
is  of  considerable  importance.  Bacteria  that  gain  access  to  the  per- 
itoneal cavity  may  be  destroyed  in  situ  by  the  bactericidal  activity  of 
the  peritoneal  serum,  which,  as  stated,  is  not  conspicuous,  or  they  may 
be  robbed  in  great  part  of  their  pathogenetic  powers  by  their  rapid 
resorption  by  the  peritoneum.  This,  it  seems,  is  of  considerable 
moment,  and  there  is  good  reason  for  belief,  that,  such  is  the  rapidity 
with  which  bacteria  are  often  absorbed  by  the  peritoneum,  they  are 
removed  from  the  peritoneal  cavity  before  they  have  had  time  to 
exert  sufficient  deleterious  activity  to  engender  inflammatory  reac- 
tion. Having  been  absorbed,  they  are  finally  destroyed  by  phago- 
cytes in  the  lymph  channels,  blood-vessels,  etc.  Frequently, 
however,  neither  of  these  factors  suffices,  and,  in  an  effort  to  resist 
general  infection,  the  peritoneum  exerts  itself  to  the  utmost  by  unit- 
ing, forming  adhesions,  and  leading  to  encapsulation  of  infectious 
foci.  The  exact  nature  of  this  process  is  still  imperfectly  under- 
stood; but  the  fact  is  well  established  that,  as  bacteria  in  cultures  may 
die  as  the  result  of  the  action  of  the  toxin  they  themselves  produce, 
so  in  such  encapsulated  foci  the  contained  bacteria,  after  the  lapse 
of  a  certain  time,  gradually  lose  their  virulence  and  finally  succumb; 
and  that  the  cellular  exudate  undergoes  various  retrograde  meta- 
morphoses, becomes  fatty,  forms  a  granular  debris,  and  is,  partly 
at  least,  removed  by  absorption.  It  is  not  only  the  encapsulation 
and  limitation  of  the  infectious  foci  per  se,  but  also  the  concomitant 
peritoneal  lesions,  that  serve  to  protect  against  general  infection. 
The  obstruction  of  the  lymphatic  stomata  and  the  regionary  lymph- 
atic radicles  by  the  coagulated  fibrin  which  also  covers  the  serosa 
subserves  the  same  useful  purpose. 

Appreciating  the  nature  and  character  of  the  powers  of  resistance 
offered  by  the  peritoneum,  the  comprehension  of  the  mode  of 
production  of  peritonitis  is  much  facilitated.  The  introduction 
of  non-pathogenic  micro-organisms  into  a  healthy  peritoneum 
is  without  morbid  consequences.  The  introduction  of  pyogenic 
micro-organisms  into  a  healthy  peritoneal  cavity  is  not  followed 
by  peritonitis,  provided  the  bacteria  be  not  excessive  either  in  number 
or  in  virulence.  Peritonitis,  however,  does  result  from  the  access 
of  pyogenic   bacteria  to   the  peritoneum   when   the  bacteria   are 


Pathology  129 

excessive  in  number  or  virulence  or  both;  that  is,  when  there  are 
excessive  demands  upon  the  resorptive  power  of  the  peritoneum, 
be  it  that  there  is  a  sudden  accession  to  the  peritoneum  of  a  large 
quantity  of  bacteria,  or  an  intermittent  or  continuous  supply  of 
bacteria  in  small  numbers;  when  the  resorptive  power  of  the  perito- 
neum is  below  the  normal;  when  the  peritoneal  cavity  contains  a 
quantity  of  fluid,  particularly  an  albuminous  fluid  susceptible  of 
decomposition — even  a  simple  ascites  is  of  significance — ^when  the 
peritoneum  is  subjected  to  mechanical  injury  at  the  site  of  the 
introduction  of  the  bacteria,  such  as  occurs  in  case  of  operative 
wounds  and  rupture  of  intra-abdominal  organs,  as  the  appendix, 
etc.;  and  when  the  patient  is  debilitated. 

The  disastrous  consequences  of  peritonitis  are  due  in  part, 
particularly  in  the  purulent  varieties,  to  the  local  suppuration,  to 
the  loss  of  the  bodily  fluids,  but  in  great  part  to  intoxication  of  the 
general  organism.  The  paramount  importance  of  this  latter  is 
evident  from  the  fact  that  the  most  severe  and  rapidly  fatal  forms 
of  peritonitis  are  unaccompanied  by  the  formation  of  any  appreciable 
exudate;  hence  they  are  not  attended  by  loss  of  the  bodily  fluids. 
The  clinical  manifestations  of  the  severe  forms  of  this  affection — 
such  as  disturbed  cerebration,  partial  coma  or  delirium,  pale  and 
"leaky"  skin,  cyanosis  of  the  lips  and  finger-tips,  dry  tongue, 
rapid  and  fleeting  pulse,  rapid  and  shallow  breathing,  etc. — are 
the  manifestations  of  intoxication  rather  than  of  infection.  The 
different  varieties  of  peritonitis,  however,  present  marked  differences 
in  the  degree  of  accompanying  intoxication.  Thus,  in  many  of 
the  cases  of  circumscribed  peritonitis  the  intoxication  is  but  slight. 
In  some  of  the  suppurative  forms  with  gangrene  of  the  appendix 
it  may,  however,  be  quite  marked.  Of  the  diffuse  forms  of  per- 
itonitis, those  attended  by  the  formation  of  pus,  though  extremely 
virulent  and  producing  marked  toxaemia,  are  less  virulent  and 
give  rise  to  a  less  degree  of  toxaemia  than  do  the  haemorrhagic 
forms  and  those  marked  by  the  absence  of  exudate.  The  latter, 
which  may  be  designated  toxic  peritonitis,  is  accompanied  by  so 
extreme  a  degree  of  toxaemia  that  the  patient  generally  succumbs 
very  quickly.  The  shock  attendant  upon  the  rupture  of  the  dis- 
eased appendix  is  of  itself  not  of  so  much  significance  in  the  sudden 
development  of  alarming  symptoms  as  is  the  rapid  absorption  of  a 
9 


130  Appendicitis 

large  quantity  of  preformed  toxins  that  are  suddenly  evacuated 
into  the  general  peritoneal  cavity.  It  is  under  such  circumstances 
that  the  great  resorptive  power  of  the  peritoneum,  of  such  significance 
in  guarding  against  infection,  becomes  the  very  agent  whereby 
the  system  is  suddenly  overpowered  by  a  large  quantity  of  these 
preformed  toxins.  The  absorption  also  of  a  quantity  of  ptomaines 
that  are  sometimes  liberated  with  the  toxins  contributes  to  the 
production  of  alarming  symptoms.  At  times,  of  course,  the  fatal 
issue  is  determined  by  pyaemia  rather  than  by  intoxication. 

Pathologically,  the  lesions  of  the  peritoneum,  like  those  of 
the  appendix,  may  be  acute  or  chronic  as  regards  their  course; 
circumscribed  or  diffuse  as  regards  their  extent;  and  serous,  sero- 
fibrinous, fibrinous,  purulent,  or  haemorrhagic  as  regards  their 
character.  Just  as  in  the  different  varieties  of  appendicitis,  there 
may  also  be  all  gradations,  from  the  mildest  peritoneal  implication 
to  the  m,ost  virulent — from  those  with  slight  circumscribed  serous 
exudate  to  the  most  severe,  malignant,  generalized,  purulent, 
haemorrhagic,  or  toxic  peritonitis.  Nevertheless,  there  are  attending 
the  various  forms  of  appendicitis  several  varieties  of  peritonitis 
which  differ  as  to  their  mode  of  production,  extent  of  implication 
of  the  peritoneum,  and  character  of  the  exudate,  and  which,  in 
consequence,  permit  of  a  practical  classification  of  the  peritoneal 
lesions  of  appendicitis.     These  will  be  described  as  follows : 

I.  Acute  Appendicular  Peritonitis. 

1.  Circumscribed   serous,    sero-fibrinous,    and    fibrinous    per- 
itonitis. 

2.  Circumscribed    purulent   peritonitis,    or   peri-appendicular 
abscess. 

3.  Diffuse  or  generalized  peritonitis. 

II.  Chronic  Appendicular  Peritonitis. 

ACUTE  APPENDICULAR  PERITONITIS. 

CIRCUMSCRIBED  SEROUS,  SERO-FIBRINOUS,  AND 
FIBRINOUS  PERITONITIS. 

By  serous  or  sero-fibrinous  peritonitis  is  understood  an  inflam- 
mation of  the  peritoneum  attended  by  the  formation  of  a  serous  or 
sero-fibrinous   exudate.     Of   all  the  varieties  of  peritonitis  com- 


Pathology  131 

plicating  appendicitis,  the  serous  is  probably  the  most  infrequently 
met  with,  and,  in  consequence,  but  little  attention  has  been  directed 
to  it.  Its  apparent  uncommon  occurrence  is  due  not  so  much 
to  its  actual  non-existence  as  to  the  fact  that  at  the  time  of  observation, 
either  at  operation  or  necropsy,  it  has  given  way  to  one  of  the  severer 
forms  of  peritonitis.  As  a  result,  however,  of  the  practice  that  has 
obtained  in  recent  years  of  operating  early  in  cases  of  appendicitis, 
sufficient  opportunity  has  been  afforded  to  note  the  not  uncommon 
occurrence  of  such  serous  or  sero-fibrinous  peritonitis. 

It  is  but  natural  to  infer  that  if  the  peritoneum  be  implicated 
in  a  mild  attack  of  appendicitis,  the  lesions  of  this  structure,  particu- 
larly in  the  early  stages,  will  also  be  mild.  For  this  reason  it  can- 
not be  doubted  that  some  at  least  of  the  severer  forms  of  peritonitis, 
particularly  the  fibrinous  (non-suppurative)  form,  and  even  also 
some  of  the  purulent  variety,  are  initiated  as  a  serous  or  sero- 
fibrinous inflammation.  The  peritonitis,  however,  in  many  of 
these  cases,  either  because  of  the  virulence  of  the  irritant  or  its 
long-continued  action,  does  not  remain  of  this  character,  but 
speedily  progresses  to  the  fibrinous  or  purulent  variety. 

Serous  or  sero-fibrinous  peritonitis  is  encountered  in  association 
with  the  milder  forms  of  appendicitis  only — acute  catarrhal  and 
mild  interstitial  appendicitis  and  the  chronic  forms  of  the  disease 
with  mild,  acute  exacerbations.  Under  such  circumstances  the 
peritoneum  covering  the  appendix  is  in  a  state  of  inflammatory 
hyperaemia.  It  is  injected,  many  of  the  vessels  being  quite  dis- 
tended and  visible  to  the  unaided  eye,  while  other  minute  ones,  by 
their  congestion,  lend  a  diffuse  redness  to  the  tissue.  In  addition, 
the  peritoneum  has  lost  its  normal  lustre,  is  slightly  opaque,  and, 
is  somewhat  rough,  velvety,  or  viscid  to  the  touch.  This  latter 
characteristic  is  dependent  upon  the  presence  of  a  serous  or  sero- 
fibrinous exudate  that,  at  times,  is  so  slight  as  to  be  scarcely  appre- 
ciable. Occasionally  rupture  of  minute  blood-vessels  occurs  and 
leads  to  haemorrhagic  foci.  These  alterations,  as  a  rule,  do  not 
extend  beyond  the  limits  of  the  peritoneal  covering  of  the  appendix. 
Exceptionally,  they  may  also  implicate  the  meso-appendix,  and 
more  rarely  the  caecum,  adjoining  coils  of  intestine,  and  the  parietal 
peritoneum.  In  certain  isolated  instances  there  may  be  in  the 
neighborhood  of  the  appendix  a  small  collection  of  serous  fluid.       ■ 


132  Appendicitis 

Sonnenburg  in  particular  believes  in  the  occurrence  of  such 
serous  peritonitis,  and  states  that  even  large  collections  of  serous 
exudate  may  be  encountered.  He  records  one  case  in  which, 
at  operation,  he  found  a  large  exudate,  consisting  of  turbid  fluid 
free  from  bacteria,  surrounded  by  a  fibrous  capsule,  in  the  neighbor- 
hood of  a  chronically  inflamed  appendix.  The  occurrence  of 
such  circumscribed  serous  exudates  is  also  spoken  of  by  Roux, 
Lennander,  Kiimmel,  Frankfurter,  Renvers,  and  others.  Nor  can 
it  be  denied  that  some  at  least  of  them  may  have  been  originally 
sero-purulent,  and  in  the  course  of  time  have  become  more  serous 
and  sterile  as  a  consequence  of  the  demise  of  the  contained  bacteria. 

Fibrinous  peritonitis  is  but  an  aggravation  or  further  stage 
of  the  serous  or  sero-fibrinous  variety  of  inflammation.  It  is  found 
in  association  with  acute  catarrhal  and  interstitial  appendicitis  of 
moderate  intensity,  and  with  cases  of  chronic  appendicitis  in  which 
there  have  been  recurrences,  the  most  recent  one  of  some  intensity. 
It  is  quite  likely  that  in  some  cases  in  which  an  early  operation 
discloses  merely  fibrinous  peritonitis,  a  later  or  deferred  operation 
would  reveal  progression  to  fibrino-purulent  peritonitis,  with  or  with- 
out perforation  of  the  appendix. 

In  cases  of  fibrinous  peritonitis  the  peritoneum  in  the  region 
of  the  appendix  is  covered  with  a  layer  of  fibrinous  deposit  of  a 
grayish  or  grayish-yellow  color  and  viscid  to  the  touch.  This 
is  intimately  adherent  to  the  underlying  peritoneum,  and  varies 
considerably  in  amount  in  different  cases.  At  times  it  is  excessively 
thin  and  watery,  from  the  admixture  of  much  serum  and  relatively 
little  fibrin,  and  differs  but  little  from  the  ordinary  serofibrinous 
exudate.  Again,  there  may  be  little  serum  and  great  amounts  of 
fibrinous  deposits.  In  the  same  case,  also,  the  amount  of  fibrinous 
exudate  may  vary  in  different  regions.  Through  the  medium  of 
this  fibrinous  or  plastic  exudate  the  appendix  and  the  neighboring 
coils  of  intestine  are  more  or  less  firmly  united  to  each  other  and  to 
the  omentum  and  parietal  peritoneum.  After  the  separation  of 
adherent  coils  of  intestine  the  exudate  may  be  stripped  off  in  suc- 
cessive layers,  revealing  the  peritoneum  markedly  congested, 
roughened,  and  lustreless.  At  times  tlie  exudate  is  so  excessive 
that  to  locate  the  appendix  requires  more  or  less  extensive  dissec- 
tion.-   Sometimes  the  appendix  still  eludes  detection,  and  is  found 


Pathology  133 

only  after  diligent  search  embedded  in  a  dense  amount  of  coagu- 
lated lymph  that  may  surround  it  to  an  extent  of  from  one  to  three 
centimetres. 

Upon  microscopical  examination  of  the  peritoneum  in  cases  of 
serous,  sero-fibrinous,  or  fibrinous  peritonitis,  dilatation  and  over- 
filling of  the  blood-vessels,  proliferation  of  the  endothelial  cells 
lining  the  peritoneum,  serous  infiltration  of  the  fibrous  layer  of  the 
latter,  and  more  or  less  round-cell  infiltration  are  detected.  On  the 
outer  layer  of  the  peritoneum  there  is  a  deposit  of  fibrin,  which,  of 
course,  varies  in  amount  in  different  cases.  It  commonly  presents 
itself  as  a  fine  network  that  forms  a  support  for  the  proliferating 
endothelial  cells  and  wandering  leucocytes.  Occasionally,  also, 
newly  formed  capillaries  are  detected.  The  cells  of  the  network 
undergo  various  degrees  of  retrograde  metamorphosis,  and  at  times 
rupture  of  the  newly  formed  capillaries  ensues  and  gives  rise  to 
haemorrhagic  foci.  The  serous  fluid  usually  contains  a  few  flocculi 
of  coagulated  lymph,  and,  even  when  quite  clear,  reveals  micro- 
scopically a  number  of  lymph  corpuscles  and  desquamated  endo- 
thelial cells. 

In  case  this  fibrinous  peritonitis  does  not  progress  to  suppura- 
tion, evidences  of  organization  become  manifest.  The  fibrin- 
ous network  acts  as  a  support  for  newly  formed  connective-tissue 
cells  and  capillaries.  This  granulation  tissue,  through  the  well- 
known  processes  of  regeneration,  is  transformed  into  fibrous  con- 
nective tissue  that  speedily  undergoes  cicatrization.  Thus  chronic 
peritoneal  adhesions  and  bands,  of  which  mention  will  be  made 
subsequently,  result. 

CIRCUMSCRIBED  PURULENT  PERITONITIS,  OR    PERI- 
APPENDICULAR ABSCESS. 

The  most  common  peritoneal  complication  of  acute  appendi- 
citis, and  clinically  the  most  important,  because  of  its  disastrous 
consequences,  is  circumscribed  purulent  peritonitis — the  formerly 
so-called  perityphlitic  abscess.  Just  as  a  severe  interstitial  or 
ulcerative  appendicitis  may  follow  a  catarrhal  or  a  mild  interstitial 
inflammation,  so  circumscribed  purulent  peritonitis  may  be  an 
aggravation  of  a  milder  variety  of  peritoneal  inflammation,  and 
may  follow  in  the  sequence  of  a  serous,  a  sero-fibrinous,  or  a  fibrin- 


134  Appendicitis 

ous  peritonitis.  Thus,  it  is  found  in  association  with  interstitial 
appendicitis  without  perforation,  with  ulcerative  appendicitis 
without  perforation,  and  it  is  always  a  concomitant  of  ulcerative 
appendicitis  with  perforation,  unless  the  peritoneal  involvement  be 
diffuse.  The  peritonitis  of  gangrenous  appendicitis  is  also  of  the 
purulent  variety.  Again,  the  acute  infection  or  exacerbation  of  the 
inflammatory  phenomena  of  a  chronically  inflamed  appendix  may 
be  the  starting-point  of  a  circumscribed  peri-appendicular  abscess. 

The  serous  and  fibrinous  exudates  already  described  in  connec- 
tion with  serous,  sero-fibrinous,  and  fibrinous  peritonitis  are  to  be 
interpreted  as  the  results  of  the  reaction  of  the  peritoneum  to  the 
action  of  an  irritant — as  an  effort  on  the  part  of  the  peritoneum  to 
protect  itself  from  general  infection.  This  exudate  thus  subserves  a 
useful  purpose.  More  than  this,  in  the  event  of  perforation  of  the 
appendix — the  perforation  in  the  majority  of  cases  occurring  into, 
rather  than  outside  of  it — ^it  has  already  formed  a  barrier  that  in 
most  instances,  for  a  time  at  least,  prevents  infection  of  the  general 
peritoneal  cavity.  It  is,  however,  not  essential  that  perforation  occur 
in  order  that  an  abscess  result.  An  exudate  originally  fibrinous 
often  becomes  fibrino-purulent  or  purulent  without  perforation  of  the 
appendix  developing. 

In  circumscribed  purulent  peritonitis,  or  peri-appendicular 
abscess,  a  greater  or  smaller  portion  of  the  peritoneal  cavity  lodges  a 
focus  of  suppuration  that  develops  at  the  site  of  the  original  source 
of  infection  and  is  walled  off  from  the  general  peritoneal  cavity  by 
more  or  less  firm  fibrino-plastic  exudate.  This  peri-appendicular 
abscess  may  develop  slowly  or  exceedingly  rapidly,  and  in  different 
cases  it  varies  much  in  size  and  in  other  characteristics.  There  may 
not  be  more  than  one  or  two  cubic  centimetres  of  pus,  in  which  case 
the  abscess  may  be  difl&cult  to  find;  on  the  other  hand,  the  abscess 
may  be  exceedingly  large,  and  may  contain  upward  of  a  litre  of  pus. 
Usually,  however,  in  an  ordinary  case  there  are  not  more  than  thirty 
cubic  centimetres  of  pus.  The  abscess  may  be  single  or  multiple, 
and  may  be  regular  or  irregular  in  outline.  It  is  not  rare  to  find 
several  pockets  of  pus  that  communicate  with  a  common  cavity. 
Under  other  circumstances  several  isolated  pockets  may  communi- 
cate with  one  another  by  narrow  and  tortuous  channels. 

The  wall  of  the  abscess  cavity  is  made  up  of  a  grayish-yellow 


Pathology  135 

or  yellowish-green  discolored  fibrino-purulent  exudate.  This  is  of 
variable  firmness  and  consistency,  and  serves  to  unite  more  or  less 
securely  the  appendix,  caecum,  neighboring  coils  of  intestine,  omen- 
tum, mesentery,  and  parietal  peritoneum.  The  pus  is  sometimes 
yellowish  in  color  and  distinctly  creamy  in  appearance.  More 
commonly,  however,  it  is  thinner  than  cream,  of  a  yellowish-green, 
brownish,  or  greenish-black  color.  Sometimes  it  is  bluish  or  green- 
ish in  color,  and  under  such  circumstances  may  reveal  Bacillus 
pyocyaneus  in  pure  culture.  It  usually  possesses  a  peculiar,  pene- 
trating, disagreeable,  faecal  odor.  At  times  it  is  distinctly  putrid,  and 
may  contain  gas,  the  latter  the  result  of  the  activities  of  contained 
bacteria  or  of  admixture  of  intestinal  gases  in  cases  of  perforation. 
In  addition  to  the  pus,  the  abscess  may  contain  more  or  less  necrotic 
remnants  of  fibrinous  exudate,  one  or  more  faecal  concretions,  and 
some  faecal  matter.  In  it  also  we  may  detect  the  more  or  less  altered 
appendix.  The  appendix,  in  whole  or  in  part,  may  appear  sus- 
pended, as  it  were,  in  the  abscess  cavity,  or  it  may  have  become 
entirely  separated  from  its  caecal  attachment  by  circular  amputation, 
and  may  float  entirely  free  in  the  pus.  More  commonly  it  will  be 
found  embedded  in  the  exudate  forming  part  of  the  limiting  wall  of 
the  abscess. 

The  situation  of  the  abscess  varies  greatly  in  different  cases,  and 
is  naturally  dependent  to  a  considerable  extent  upon  the  situation, 
the  direction,  the  length,  the  mobility,  and  the  possible  fixation  of  the 
appendix.  In  exceptional  cases  the  appendix  and  the  caecum  are 
found  in  anomalous  positions,  which  in  the  event  of  appendicitis 
exert  considerable  influence  in  determining  the  situation  of  possible 
peri-appendicular  suppuration.  In  the  majority  of  cases,  however, 
it  is  possible  to  divide  these  abscesses,  with  respect  to  their  situation, 
into  certain  groups,  of  which  Sonnenburg  distinguishes  four  that  are 
of  common  occurrence:  (i)  Anteriorly;  (2)  posteriorly;  (3)  me- 
dianly;  (4)  in  the  pelvis.  In  the  first,  according  to  him,  there  at 
first  occurs  an  adhesion  of  the  coils  of  intestine  that  normally  are 
almost  always  found  in  front  of  the  caecum.  Beneath  these  the 
abscess  originates.  As  it  increases  in  size,  the  adherent  coils  of 
intestine  are  displaced  and  the  pus  reaches  the  parietal  peritoneum. 
The  latter  thus  forms  the  anterior  boundary  of  the  abscess,  the  caecum 
the  posterior  and  median  boundary,  and  the  iliac  fossa  the  outer 


136  Appendicitis 

boundary.  In  addition,  various  coils  of  intestine  may  assist  in  the 
limitation  of  the  abscess  above.  In  these  cases  the  appendix  is 
usually  found  anteriorly  in  the  iliac  fossa  or  attached  to  the  outer  or 
lower  surface  of  the  caecum.  When  situated  posteriorly,  the  abscess 
is  limited  anteriorly  by  the  posterior  surface  of  the  caecum,  and 
posteriorly  by  the  posterior  abdominal  wall.  In  these  cases  the 
appendix  is  usually  attached  to  the  posterior  surface  of  the  caecum 
and  is  directed  upward.  These  abscesses  are  situated  higher  than 
those  of  the  former  group,  and,  spreading  out  in  the  region  of  the 
kidney,  they  may  give  rise  to  perirenal  suppuration;  or,  reaching  the 
lumbar  region,  they  may  cause  protrusion  of  it.  Abscesses  situated 
medianly  are  bounded  laterally  or  externally  by  the  median  aspect  of 
the  caecum  and  ascending  colon;  posteriorly,  by  the  meso-colon; 
mesially,  anteriorly,  and  above,  by  various  coils  of  intestine.  Attain- 
ing a  considerable  size,  these  abscesses  may  reach  to,  and  be  limited 
by,  the  bladder.  Abscesses  situated  in  the  pelvis  commonly  occupy 
the  right  half  of  it,  though  they  frequently  extend  also  to  the  left. 
They  are  often  situated  in  the  retro-vesical  space — ^in  women,  in 
Douglas's  cul-de-sac.  The  appendix  is  usually  detected  in  the  upper 
and  outer  wall  of  the  abscess;  frequently,  however,  it  may  be  adherent 
to  the  bladder,  uterus,  tubes,  ovary,  rectum,  etc.  This  classification 
had  been  adopted  independently  by  Deaver,  who,  in  addition  to 
describing  the  foregoing  four  varieties  of  peri-appendicular  abscess, 
is  in  the  habit  of  speaking  of  a  fifth  variety — the  diffuse  abscess,  or 
diffuse  purulent  peritonitis.  As  already  intimated,  these  peri- 
appendicular abscesses  may  be  encountered  in  most  unusual  situa- 
tions. Of  such  may  be  mentioned:  Near  the  gall-bladder,  near 
the  spleen,  in  the  region  of  the  umbilicus,  beneath  the  right  lobe  of  the 
liver,  beneath  the  diaphragm,  in  the  left  iliac  fossa,  in  a  hernia — 
inguinal  or  femoral,  of  either  the  right  or  left  side — etc. 

Heretofore  mention  has  been  made  only  of  the  suppurative  com- 
plications of  appendicitis  that  occur  within  the  peritoneal  cavity — to 
circumscribed  appendicular  peritonitis.  It  must,  nevertheless,  be 
stated  that,  in  the  event  of  suppuration  ensuing  upon  an  attack  of 
appendicitis,  it  is  not  necessary  that  the  collection  of  pus  be  situated 
primarily  within  the  peritoneal  cavity.  The  abscess  may  be  retro- 
peritoneal— the  formerly  so-called  para-typhlitic  abscess.  This  may 
be  due  to  one  of  several  causes:    (i)  It  may  occur  if  the  appendix 


Pathology  137 

be  situated  retro-peritoneally,  as  happens,  as  has  been  mentioned 
already,  in  about  2  per  cent,  of  the  cases.  In  case  infectious  material 
penetrate  the  wall  of  the  appendix,  or  if  perforation  of  the  organ  occur, 
the  retro-peritoneal  connective  tissues  are  those  first  attacked,  and  a 
retro-peritoneal  abscess  results.  (2)  Such  may  also  develop, 
although  the  appendix  be  situated  intra-peritoneally,  if  the  perfora- 
tion occur  into  the  meso-appendix.  Under  such  circumstances  the 
liberated  infectious  material  dissects  its  way  between  the  two  layers  of 
the  meso-appendix,  and  finally  reaches  the  retro-peritoneal  connec- 
tive tissues,  where  the  abscess  originates.  It  is  quite  likely  also, 
that,  in  the  absence  of  perforation,  some  retro-peritoneal  abscesses 
may  be  produced  by  virulent  infectious  material  being  carried  by  the 
lymphatics  of  the  meso-appendix  to  the  retro-peritoneal  connective 
tissues.  (3)  Such  retro-peritoneal  suppuration  may  also  occur  in 
some  cases  in  which  rather  firm  adhesions  bind  the  appendix  to  the 
posterior  layer  of  the  peritoneum.  In  these  cases  this  posterior 
layer  of  the  peritoneum  may  have  become  so  altered  by  the  inflam- 
mation that,  in  the  event  of  perforation,  it  offers  but  little  resistance 
to  the  advances  of  virulent  bacteria  and  their  toxins.  Being  less 
resistant  than  the  firm  adhesions,  it  gives  way  first,  and  there  thus 
occurs  a  perforation  of  the  appendix,  directly  through  its  peritoneal 
coat,  some  adhesions,  and  the  posterior  layer  of  the  peritoneum,  into 
the  retro-peritoneal  connective  tissues.  A  retro-peritoneal  abscess 
results,  without  any  associated  intra-peritoneal  suppuration.  (4) 
Retro-peritoneal  abscesses  may  occur  secondarily  by  perforation 
through  the  posterior  layer  of  the  peritoneum  of  an  abscess  that 
originated  intra-peritoneally. 

Such  retro-peritoneal  abscesses  sometimes  give  rise  to  the  most 
extensive  phlegmonous  infiltration.  Following  the  course  of  the 
iliac  vessels,  they  may  present  themselves  beneath  Poupart's  liga- 
ment; they  may  involve  the  region  of  the  kidney  and  engender  a 
large  perirenal  abscess,  with  or  without  implication  of  the  kidney; 
they  may  ascend  behind  the  liver  and  spread  out  over  its  surface, 
producing  an  extensive  subdiaphragmatic  abscess;  they  may  per- 
forate into  the  pleura  and  produce  an  empyema;  they  may  penetrate 
the  lung  and  give  rise  to  a  pulmonary  abscess,  that  may  or  may  not  be 
expectorated  externally;  they  may  perforate  again  into  the  peritoneal 
cavity,  etc. 


138  Appendicitis 

Reverting  again  to  peri-appendicular  abscess  situated  primarily 
within  the  peritoneal  cavity,  it  will  be  recalled  that  it  was  stated  that 
it  may  attain  a  capacity  of  a  litre.  Such  an  occurrence,  however,  is 
most  exceptional.  Usually,  if  the  abscess  be  progressive,  before  it 
has  attained  such  a  size  one  of  several  events  will  have  ensued.  There 
will  either  have  been  produced  a  diffusing  peritonitis — of  which  men- 
tion will  be  made  later — or,  if  the  adhesions  be  sufficiently  firm  to 
protect  the  general  peritoneal  cavity  from  infection,  the  abscess  will 
probably  have  ruptured  in  one  of  several  directions.  As  the  abscess 
increases  in  size  it  not  only  compresses  the  adjacent  organs  and 
tissues,  but  the  latter  themselves  become  the  seat  of  more  or  less 
superficial  or  deep  inflammation  with  purulent  infiltration  and 
necrosis.  The  various  organs  and  tissues  of  the  region  of  the  appen- 
dix permit  of  a  certain  amount  of  compression  without  much  resent- 
ment, but  when  the  limit  has  been  reached,  the  abscess  of  necessity 
ruptures  in  the  direction  of  least  resistance.  As  some  of  the  organs 
of  this  region,  because  of  their  implication  in  the  inflammation,  are 
themselves  the  points  of  least  resistance,  it  is  into  them  that  rupture 
often  occurs.  Certain  organs,  however,  are  much  more  likely  to  be 
the  seat  of  such  perforation  than  others.  The  relative  frequency  of 
perforations  into  different  tissues  and  organs  is  indicated  by  Sonnen- 
burg,  who  cites  the  reports  of  various  observers.  These  include  a 
total  of  424  cases,  the  combined  statistics  of  Bull,  Langheld,  Einhorn, 
Kjafft,  and  Paulier.  Collectively,  the  most  frequent  perforations 
were  as  follows. 

Through  the  abdominal  wall 46 

Into  the  caecum 40 

Into  the  peritoneal  cavity 8 

Into  the  pleural  cavity 6 

Into  the  ascending  colon 4 

Into  the  rectum 4 

Into  the  ileum 3 

Into  the  bladder 3 

Into  the  uterus i 

It  was  misconception  of  the  real  direction  of  the  perforation  in 
certain  cases  of  peri-appendicular  abscess  that,  in  part  at  least,  led 
to  the  erroneous  view  maintained  some  years  ago,  that  appendicitis 
was  typhlitis,  perityphlitis,  and  par  a- typhlitis,  and  that  the  suppura- 
tive forms  of  the  latter  were  the  result  of  perforation  of  the  caecum. 


Pathology  139 

Suppurative  disease  about  the  caecum  did  not,  as  was  then  held, 
result  from  disease  and  perforation  of  the  caecum.  On  the  contrary, 
perforation  of  the  caecum,  in  many  of  these  cases,  was  due  to  rupture 
into  the  caecum  of  an  already  formed  peri- appendicular  abscess; 
in  other  cases  it  was  due  to  a  direct  rupture  of  the  appendix  into  the 
caecum,  with  which  it  had  formed  adhesions.  There  occur,  however, 
cases  of  perforation  of  the  caecum  due  to  some  morbid  condition  of 
that  viscus,  such  as  large  enteroliths,  etc. 

In  addition  to  the  previously  detailed  directions  of  rupture  of 
peri-appendicular  abscesses  rare  instances  of  perforation  into  other 
organs  have  been  encountered.  Thus,  cases  have  been  reported 
in  which  the  abscess  ruptured  into  the  gall-bladder,  into  the  duo- 
denum, into  the  vagina,  into  the  ureter  (pelvis  of  the  kidney),  etc.; 
and  Sonnenburg  mentions  a  case  in  which,  probably  through 
infection  of  a  patulous  vaginal  tunic  of  the  testicle,  there  resulted  a 
pyocele  of  the  testicle. 

But  other  secondary  disastrous  consequences  ensue  upon  the 
persistence  of  the  abscess.  Thus,  lymphangitis  and  lymphadenitis, 
thrombo-phlebitis  and  pylephlebitis  may  occur.  The  thrombo- 
phlebitis usually  affects  the  mesentery  and  portal  veins,  but  throm- 
bosis of  the  iliac  and  femoral  veins  of  either  the  right  or  the  left  side, 
or  of  both,  may  develop.  The  pylephlebitis  is  sometimes  of  the 
mild  or  non-infectious  variety — the  so-called  adhesive  pylephlebitis — 
in  which  the  thrombus  leads  to  partial  or  complete  obliteration  of 
the  portal  vein.  Frequently,  however,  the  process  is  infectious;  the 
thrombus  becomes  purulent  and  leads  first  to  abscess  of  the  liver,  and 
subsequently  to  general  infection,  or  pyaemia.  Again,  erosion  of  a 
principal  branch  of  the  mesenteric  vein  has  been  encountered 
(Aufrecht),  and  implication  of  a  branch  of  the  inferior  vena  cava, 
with  consecutive  pulmonary  abscesses,  is  not  unknown.  Of  other 
conditions  secondary  to  the  abscess  may  be  mentioned :  Erosion 
of  the  internal  iliac  artery  or  of  one  of  its  branches;  iliopsoitis; 
peri-hepatitis;  suppurative  pleuritis;  endocarditis;  parotitis;  menin- 
gitis; abscess  of  the  kidney,  spleen,  etc.;  disease  of  the  female  geni- 
talia; and  general  septicaemia,  pyaemia,  etc. 

It  cannot  be  denied,  however,  that,  under  exceptional  circum- 
stances, absorption  of  pus  may  occur.  This  is,  nevertheless,  a  very 
rare  event,  and  ensues  only  when  the  abscess  is  very  small  and  the 


I40  Appendicitis 

virulence  of  the  contained  bacteria  very  slight.  Under  such  circum- 
stances the  abscess  gradually  becomes  sterile,  then  inspissated,  and 
there  may  result  the  formation  of  a  thick  mass  of  indurative  con- 
nective tissue  which  rarely  has  been  found  the  seat  of  calcareous 
infiltration.  Under  other  circumstances  the  abscess  may  remain 
fluid  and  encysted — surrounded  by  a  firm  connective-tissue  capsule. 
Of  recent  years,  as  the  nature  of  appendicitis  is  becoming  more 
thoroughly  appreciated,  and  the  appropriate  treatment  more  gener- 
ally undertaken,  the  previously  detailed  disastrous  complications 
are  becoming  progressively  less.  The  more  universal  become  the 
early  recognition  and  the  prompt  surgical  evacuation  of  appendicular 
and  peri-appendicular  suppuration  or  the  removal  of  the  diseased 
appendix  before  the  supervention  of  suppuration,  the  less  frequent 
are  the  secondary  results  of  such  collections  of  pus.  It  is  for  this 
reason  that  they  whose  practice  it  is  to  operate  early  in  cases  of  appen- 
dicitis do  not  meet  with  these  complications  so  frequently  as  do  they 
who  delay  operation. 

DIFFUSE  OR  GENERALIZED  PERITONITIS. 

In  diffuse  or  generalized  peritonitis  the  entire,  or  almost  the 
entire,  visceral  and  parietal  peritoneum  are  involved  in  the  inflam- 
matory processes.  Such  peritonitis  may  develop  in  a  variety  of 
ways,  and  its  pathological  anatomy  differs  considerably  in  different 
cases.  It  is  found  associated  with  severe  cases  of  acute  interstitial 
appendicitis  without  perforation,  with  ulcerative  appendicitis  with 
or  without  perforation,  and  with  gangrene  of  the  appendix.  Several 
types  of  diffuse  or  generalized  peritonitis  may  be  distinguished, 
and  a  classification  may  be  based  not  only  upon  the  character  of 
the  pathological  alterations,  but  also  upon  the  manner  of  their 
production. 

Thus,  there  is  a  form  that  may  develop  by  gradual  progression 
from  a  circumscribed  purulent  peritonitis — the  progressive  fihrino- 
purulent  peritonitis  of  Mikulicz.  This  variety  of  general  peritonitis 
is  the  slowest  of  all  forms  in  its  diffusion.  From  the  original  focus 
of  infection,  which  may  be  a  peri-appendicular  abscess  or  a  small 
perforation — the  perforation  occurring  at  a  time  when  limiting  ad- 
hesions have  not  yet  formed — the  entire  peritoneum,  step  by  step,  as 


Pathology  141 

it  were,  becomes  implicated.  As  this  occurs,  each  new  portion  that 
is  affected  becomes  walled  off  from  the  remaining  unaffected  perito- 
neum by  more  or  less  firm  adhesions,  in  a  manner  similar  to  that 
which  limits  the  original  infectious  focus  or  surrounds  the  appendix 
before  it  has  perforated.  These  adhesions,  which  may  unite  portions 
of  the  intestine  and  omentum  with  any  of  the  abdominal  organs  or 
with  the  parietal  peritoneum,  thus  serve  to  protect  the  remaining 
peritoneum  from  sudden  infection.  These  adhesions,  in  the  major- 
ity of  instances,  are  at  first  purely  fibrinous  in  nature.  However, 
they  speedily  become  fibrino-purulent  and  purulent,  and  there  are 
thus  formed,  in  various  portions  of  the  peritoneum,  pockets  of  pus 
that  are  more  or  less  separated  from  one  another.  Some  of  them 
are  entirely  isolated,  but  many  of  them  may  communicate  with  one 
another  by  more  or  less  tortuous  channels.  Gradual  leakage  of 
the  infectious  material  occurs,  additional  portions  of  the  peritoneum 
are  involved,  new  adhesions  (limiting  barriers)  are  found,  new  foci 
of  suppuration  develop,  until  finally  the  entire  peritoneum  may 
become  implicated.  It  is  rather  uncommon  to  j&nd  the  entire 
peritoneum  involved;  there  usually  remain  larger  or  smaller  areas 
that  seem  to  have  resisted  the  onslaughts  of  the  infection,  and  these 
are  always  separated  from  the  affected  peritoneum  by  the  fibrinous 
wall.  Careful  search  is  sometimes  necessary  not  only  to  detect 
these  unaffected  regions,  but  also  to  determine  the  situation  of  some 
of  the  pockets  of  pus. 

In  another  series  of  cases  there  occurs  a  diffuse  or  generalized 
purulent  or  suppurative  peritonitis  without  noteworthy  fibrinous 
exudate,  and  consequently  with  but  slight  and  friable  adhesions 
between  the  coils  of  intestine,  omentum,  abdominal  organs,  and 
parietal  peritoneum.  Such  peritonitis  develops  when  perforation 
of  the  appendix  occurs  suddenly  and  soon  after  the  onset  of  the 
disease— at  a  time  when  the  peritoneum  has  not  yet  had  time  to 
form  a  plastic  exudate;  when  a  large  and  ill  circumscribed  empyema 
of  the  appendix  suddenly  bursts;  when  there  occurs  a  sudden  gan- 
grene of  an  appendix  that  is  not  well  surrounded  by  adhesions;  and 
when,  for  any  reason  the  adhesions  limiting  a  peri- appendicular 
abscess  suddenly  give  way  and  Hberate  a  large  quantity  of  pus. 
Thus,  the  peritoneal  lesions  vary  somewhat,  depending  upon 
whether  the  ulcerative  processes  in  the  appendix,  and  consequently 


142  Appendicitis 

the  perforation,  develop  slowly  or  rapidly.  If  the  former,  the  peri- 
toneum has  had  time  to  form  a  greater  or  less  amount  of  plastic 
exudate  that  completely  surrounds  the  appendix,  and,  in  the  event  of 
perforation,  a  circumscribed  peritonitis  or  abscess  results,  as  has 
already  been  detailed.  If  the  perforation  develop  suddenly,  the 
appendicular  contents  are  poured  forth  into  the  free  peritoneal 
cavity.  The  intensity  of  the  resulting  inflammatory  lesions  depends 
upon  the  amount,  the  fluidity,  the  virulence,  and  the  rapidity  of 
the  evacuation  of  the  appendicular  contents.  These,  having  gained 
access  to  the  general  peritoneal  cavity,  are  rapidly  dispersed  through 
extensive  portions  of  the  peritoneum  by  the  peristaltic  action  of  the 
intestines,  and  a  diffuse  purulent  peritonitis  ensues. 

In  this  variety  of  inflammation  the  peritoneum  is  the  seat  of 
an  intense  inflammatory  hyperemia;  it  is  opaque  and  lustreless, 
and  is  covered  with  a  small  amount  of  a  grayish-yellow  or  yellowish- 
green,  veil-like,  slimy,  viscid  exudate.  These  lesions,  as  a  rule,  are 
not  distributed  with  uniformity  throughout  the  peritoneum,  but  are 
commonly  more  marked  near  the  seat  of  infection.  It  is  not  unusual, 
however,  to  find  them  affecting  the  peritoneum  of  the  small  and  large 
intestines,  the  omentum,  the  mesentery,  the  solid  abdominal  organs, 
and  the  abdominal  wall.  The  slight  amount  of  exudate  may  serve 
loosely  to  unite  neighboring  loops  of  intestine,  but,  as  a  rule,  there 
are  no  firm  adhesions  unless  they  be  old.  The  exudate,  being 
attached  loosely,  often  appears  as  a  shredded  covering  of  the  intes- 
tine, and  the  unattached  ends  of  the  shreds  can  frequently  be  detected 
floating  upon  the  surface  of  the  pus  contained  within  the  peritoneal 
cavity.  At  times  these  shreds  become  entirely  detached  from  the 
intestine  and  float  free  in  the  pus.  The  pus  varies  considerably 
in  different  cases.  At  times  there  is  relatively  little;  again,  the 
amount  is  excessive — a  litre  or  more,  and  this  within  a  short  time 
of  the  onset  of  the  attack.  For  a  time,  at  least,  it  is  freely  movable, 
and,  following  the  laws  of  gravity,  seeks  the  dependent  portions  of 
the  peritoneal  cavity — ^recesses  between  adjoining  coils  of  intestine, 
the  pelvis,  and  the  prerenal  regions.  Later,  if  some  adhesions  are 
formed,  there  may  occur  more  or  less  circumscribed  collections  of 
pus  in  various  other  regions.  In  character  the  pus  is  rarely  thick 
and  creamy;  it  is  usually  rather  thin,  limpid,  of  a  greenish-yellow 
color,  at  times  of  a  brownish  tint,  and  of  a  distinctly  faecal  odor. 


Pathology  143 

At  times  this  variety  of  peritonitis  assumes  markedly  putrid 
characteristics — putrid  peritonitis.  The  peritoneum  is  swollen, 
congested,  softened,  and  of  a  turbid  grayish  or  grayish-red,  opaque 
color.  The  exudate  is  usually  rather  small  in  amount,  of  a  ti^rbid 
grayish,  grayish-red,  or  grayish-brown  color,  and  exceedingly 
malodorous.  At  times  it  may  contain  gas,  even  in  the  absence  of 
perforation  of  the  appendix.  This  is  of  most  unusual  occurrence; 
but  despite  the  prevailing  differences  of  opinion,  it  cannot  be 
denied  that  certain  gas-forming  bacteria  may  penetrate  the  diseased 
wall  of  the  appendix  and  give  rise  to  the  formation  of  gas  in  the 
peritoneal  cavity,  even  in  the  absence  of  perforation  of  the  appendix. 
As  a  matter  of  fact,  however,  this  variety  of  peritonitis  is  usually 
found  in  association  with  gangrene  of  the  appendix  with  perforation. 
As  a  consequence,  the  production  of  gas  is  readily  explicable,  as  is 
also  the  fact  that  at  times  portions  of  the  gangrenous  appendix,  a 
faecal  concretion,  or  rarely,  a  foreign  body  can  be  detected  free  in  the 
peritoneal  pus. 

Under  other  circumstances  the  peritonitis  assumes  a  haemorrhagic 
character — hamorrhagic  peritonitis.  The  peritoneum  is  excessively 
congested  and  the  seat  of  more  or  less  extensive  haemorrhagic  suffu- 
sions. There  is  also  some  admixture  of  blood  with  the  purulent 
or  sero-purulent  exudate,  which  gives  it  a  reddish  or  brownish  color. 
Otherwise  the  lesions  do  not  differ  from  those  already  detailed. 

The  last-named  varieties  of  peritonitis  are  closely  allied  to 
that  even  more  rapidly  fatal  form  known  as  septic  peritonitis,  or 
peritoneal  sepsis.  In  view  of  the  fact,  however,  that  the  symptoms 
and  pathological  lesions  of  none  of  the  varieties  of  peritonitis  are 
unassociated  with  the  activities  of  bacteria,  the  reservation  of  the 
term  septic —  a  term  variously  interpreted  at  present — to  designate 
a  certain  class  of  inflammations  of  the  peritoneum  is  open  to  objec- 
tion. As  the  clinical  and  pathological  features  of  this  variety  of 
peritonitis  are  due  to  the  rapid  absorption  of  a  large  quantity  of 
virulent  toxins,  it  may  be  preferable  to  designate  it  toxic  peritonitis. 
Clinically,  the  predominating  characteristics  of  this  variety  are  not 
only  the  evidences  of  disease  of  the  peritoneum,  but  also,  and  par- 
ticularly, the  indications  of  profound  intoxication,  which,  as  is 
well  known,  manifest  themselves  principally  by  disturbances  of  the 
nervous  system  and  of  the  general  economy.     Pathologically,  cases 


144  Appendicitis 

of  this  class  differ  from  those  of  the  other  classes  by  the  relative 
meagerness  of  the  lesions.  In  the  other  varieties  of  peritonitis  the 
peritoneum  is  able  to  offer  some  resistance  to  the  spread  of  the  infec- 
tion, and  this  resistance  is  manifest  by  the  evidences  of  inflammation 
and  the  attempts  at  restriction  of  the  infectious  focus  to  a  portion  of 
the  peritoneum.  In  cases  of  toxic  peritonitis,  however,  the  peri- 
toneum, and  secondarily  the  general  economy,  are  suddenly  over- 
whelmed with  such  a  quantity  of  virulent  toxins  that  the  patient 
may  succumb  before  the  peritoneum  is  able  even  partly  to  recover 
itself  and  to  attempt  an  adequate  resistance. 

The  lesions  detected  in  these  cases  are  often  inconspicuous. 
Aside  from  injection  of  the  peritoneum,  either  in  whole  or  in  part, 
there  may  be  no  deviations  from  the  normal.  In  other  cases  the 
congestion  may  be  more  intense  and  widespread,  and  there  may  be 
minute  haemorrhages  beneath  the  serosa;  in  addition,  the  per- 
itoneum may  be  a  little  less  glistening  than  normally,  and  there  may 
be  a  slight  amount  of  free  fluid.  The  latter  is  usually  small  in 
amount,  thin,  limpid,  and  of  a  yellowish-green  color  and  somewhat 
malodorous.  At  times  the  peritoneum  is  quite  dry.  There  may 
also  be  a  diffuse,  infectious,  serous  peritonitis,  as  described  by 
Tietze.  Under  other  circumstances  portions  of  the  intestine  may 
be  distended,  whereas  others  may  preserve  their  normal  calibre. 
Here  and  there  a  few  fibrinous  flakes  may  be  seen,  but  firm  adhesions 
are  never  encountered.  The  spleen  is  enlarged  and  there  is  cloudy 
swelling  of  the  liver,  kidneys,  heart  muscle,  etc. 

CHRONIC  APPENDICULAR  PERITONITIS. 

If  an  attack  of  sero-fibrinous  or  fibrinous  peritonitis  compli- 
cating appendicitis  take  a  favorable  course — that  is,  do  not  go  on 
to  suppuration — or  if  the  appendix  be  not  removed  by  operation, 
the  exudate,  as  has  already  been  intimated,  undergoes  the  ordi- 
nary alterations  characteristic  of  the  formation  of  fibrous  tissue. 
There  thus  result  bands  of  adhesions  that  unite  the  appendix,  por- 
tions of  intestine,  omentum,  mesentery,  and  parietal  peritoneum. 
The  longer  the  affection  of  the  appendix  has  continued,  and  the 
more  numerous  and  severe  have  been  the  recurrences,  the  more 
certain  are  peritoneal  adhesions  to  be  found,  and  the  more  firm  and 


Pathology  145 

extensive  are  they  Hkely  to  be.  After  the  removal  of  the  diseased 
appendix  by  operation  the  remaining  exudate  always  tends  to  organ- 
ization and  cicatrization. 

The  macroscopical  appearances  in  cases  of  chronic  peritonitis 
vary  somewhat,  depending  upon  whether  the  examination  be  made 
during  a  recurrence  or  during  the  interval  between  attacks.  Gen- 
erally, however,  the  appendicular  peritoneum — usually,  also  that 
of  the  meso-appendix — is  congested,  thickened,  opaque,  and  harder 
than  normal.  The  appendix  is  more  or  less  firmly  united  to  the 
caecum,  colon,  omentum,  intestine,  mesentery,  parietal  peritoneum, 
or  some  of  the  viscera  by  means  of  bands  of  adhesions  that  vary  much 
in  thickness  and  firmness.  They  may  be  slight,  long,  much  attenu- 
ated, and  readily  broken,  or  they  may  be  short,  very  thick,  and  ex- 
ceedingly dense  and  fibrous.  Not  only  is  the  appendix  often  united 
to  the  structures  just  enumerated,  but  the  latter  are  themselves  fre- 
quently firmly  united  with  one  another.  A  portion  of  the  omentum, 
the  appendix,  and  a  loop  of  intestine  may,  with  adhesions,  form  so 
dense  a  mass  that  only  careful  search  reveals  the  situation  of  the  ap- 
pendix, and  the  most  painstaking  dissection  is  requisite  to  remove 
it.  This  may  also  be  true  of  the  caecum  and  of  other  portions  of  the 
intestine,  which  are  often  bound  down,  twisted,  constricted,  and 
dislocated  by  bands  of  adhesions  of  various  characteristics. 

The  associations  that  the  appendix  forms  with  other  organs 
by  the  medium  of  these  bands  naturally  depend  upon  its  situation, 
and  this,  in  certain  cases,  is  not  independent  of  the  great  mobility 
of  the  organ.  In  its  ordinary  situation  the  appendix  is,  of  course, 
most  frequently  united  with  the  caecum;  then,  in  order  of  frequency, 
the  peritoneum  of  the  right  iliac  fossa,  the  mesentery,  the  small  in- 
testine (ileum),  the  omentum,  and  the  colon.  In  women  it  is  often 
adherent  to  the  right  uterine  adnexa.  When  in  unusual  situations, 
or  when  excessively  long  and  motile,  the  appendix  may  have 
formed  adhesions  with  almost  any  of  the  intra-peritoneal  organs — 
the  duodenum,  gall-bladder,  liver,  spleen,  ureter,  bladder,  rectum, 
left  uterine  adnexa,  etc. 

These  adhesions  are  of  varying  importance.  If  they  be  small, 
of  slight  extent,  and  yielding,  they  may  be  devoid  of  portentous 
significance.  On  the  other  hand,  they  are  commonly  distinctly 
detrimental  to  health.     They  contribute  to  renewed  attacks  of  ap- 


146  Appendicitis 

pendicitis  by  restricting  the  free  motion  and  the  peristaltic  action  of 
the  appendix,  and  by  causing  compression,  strictures,  twists,  angu- 
lations, etc.,  of  the  organ.  In  addition,  they  often  engender  the 
most  disastrous  intestinal  conditions.  By  their  mere  adhesion  to 
portions  of  the  bowel  they  inhibit  peristalsis,  and  by  their  contraction 
they  may,  by  compressing  or  encircling  the  bowel,  cause  intestinal 
obstruction,  angulation,  or  strangulation.  They  may  also  compress 
the  ureter  and  give  rise  to  hydronephrosis  and  pyonephrosis,  and 
produce  a  variety  of  clinical  manifestations  by  reason  of  their  con- 
nection with  the  liver,  spleen,  bladder,  ovary,  etc.  Von  Frisch  in 
an  interesting  study  of  cases  of  appendicitis  associated  with  a  hema- 
turia reports  a  case  of  his  own  and  one  of  von  Amstel  where  the 
blood  was  seen  at  cystoscopy  to  be  coming  from  the  left  ureter  and 
associated  with  a  tumor  mass  in  the  left  loin.  An  exploratory  lapa- 
rotomy showed  the  tumor  to  be  due  to  angulations  of  the  splenic 
flexure  caused  by  adhesions  of  appendiceal  origin,  the  tumor  mass 
pressing  on  the  kidney  pedicle  creating  sufficient  congestion  in  this 
organ  to  cause  a  hematuria.  Adhesions  on  the  contrary,  are  not 
altogether  without  value.  Contributing,  as  they  do,  to  recurrences 
of  appendicitis,  in  the  event  of  such  developing  and  perforation 
ensuing  they  have  formed  a  barrier  that,  for  a  time  at  least,  effect- 
ually prevents  infection  of  the  general  peritoneal  cavity.  Theoreti- 
cally, at  least — especially  if  they  surround  the  appendix  or  bind  it 
to  the  wall  of  the  pelvis — as  they  contract  they  assist  in  the  constric- 
tion and  obliteration  of  the  lumen  of  the  organ.  If  the  latter  oc- 
curs, the  likelihood  of  recurrence  of  the  inflammation  is  excluded. 

The  frequency  of  these  adhesions  is  indicated  by  the  statistics 
of  Leichtenstern,  who  found,  among  1541  cases  of  intestinal  obstruc- 
tion, 34  resulting  from  disease  of  the  appendix. 

THE   BACTERIOLOGY. 

As  the  basis  of  a  discussion  of  the  pathogenetic  role  of  bacteria 
in  appendicitis  the  results  of  the  bacteriological  investigations  of 
286  appendices  removed  by  operation  may  be  detailed.  The 
first  inoculation  in  each  case  was  made  from  the  lumen  of  the 
appendix  after  aseptic  incision  of  its  wall,  and  the  inoculation  was 
always  made  from  the  seat  of  most  manifest  disease.  At  times 
inoculations  were  also  made  from  the  exudate  on  the  peritoneal 


Pathology  147 

surface  of  the  appendix,  from  pus  of  the  abscess,  from  free  pus  in 
the  peritoneal  cavity,  and  from  drainage  fluid  subsequent  to  the 
operation.  The  results  of  these  later  inoculations  in  no  cases  differed 
from  those  of  the  primary  inoculations  from  the  lumen  of  the  appen- 
dix. Inoculations  in  the  first  place  were  made  into  bouillon  or 
into  agar  tubes,  or  both.  Subsequently,  in  many  of  the  cases, 
Petri-dish  cultures  were  made,  and  later  various  other  inoculations, 
for  the  purpose  of  fully  establishing  the  identity  of  the  bacteria 
under  investigation.  In  some  instances,  also,  cover-slip  prepara- 
tions were  made  directly  from  the  pus  or  other  contents  of  the  lumen 
of  the  appendices,  from  the  exudate  on  the  peritoneal  surface,  or  of 
the  free  pus.  Of  the  286  appendices  examined  bacteriologically, 
128  were  instances  of  acute  appendicitis;  158  of  chronic  appendicitis. 
The  results  of  the  examinations  may  be  tabulated  as  follows: 

Acute  appendicitis: 

Bacterium  coli  commune  alone 93  cases  (72  .656  per  cent.). 

Bacterium  coli  commune  and  Staphylococcus 

pyogenes  aureus 17  cases  (13  .28    per  cent.). 

Bacterium    coli    commune    and    Streptococcus 

pyogenes 6  cases  (  4 .  69    per  cent.) . 

Bacillus  pyocyaneus  alone 6  cases  (  4 .69    per  cent.). 

Staphylococcus  pyogenes  albus  alone 3  cases  (  2  .344  per  cent.). 

Staphylococcus  pyogenes  aureus  alone i    case  (0.78    per  cent.). 

Bacterium  coli  commune  and  Staphylococcus 

pyogenes  citreus i    case  (  o . 78    per  cent.). 

No  growth ■ I    case  (0.78    per  cent.) . 

Total 128  cases  (100 .00  per  cent.). 

The  following  were  the  results  of  the  bacteriological  examina- 
tions in  the  cases  of  chronic  appendicitis: 

Bacterium  coli  commune  alone 142  cases  (89 .873  per  cent.). 

Bacterium  coli  commune  and  Staphylococcus 

pyogenes  aureus 7  cases  (  4 .  43    per  cent.) . 

Bacillus  pyocyaneus  alone 2  cases  (  i  .266  per  cent.). 

Bacterium  coli  commune,  Staphylococcus  pyo- 
genes aureus,  and  Staphylococcus  pyogenes 
albus I  case    (  o .  633  per  cent.) . 

Staphylococcus  pyogenes  aureus  alone i  case    (  0.633  per  cent.). 

Bacterium    coli    commune    and    Bacillus    pro- 

digiosus I  case    (0.633  per  cent.). 

No  growth 4  cases  (  2  .  532  per  cent.) . 

Total 158  cases  (100.00  per  cent.). 


148  Appendicitis 

From  the  foregoing,  therefore,  it  is  evident  that  Bacterium  coli 
commune  was  found  alone  in  72.65  per  cent,  of  the  acute  cases  and 
in  89.873  per  cent,  of  the  chronic  cases;  that  it  was  found  either 
alone  or  in  combination  with  other  bacteria  in  117  (91.4  per  cent.) 
of  the  acute  cases  and  in  151  (96.2  per  cent.)  of  the  chronic  cases. 
Although  these  facts  are  extremely  suggestive,  the  relation  of 
Bacterium  coli  commune  to  the  development  of  appendicitis  and 
consecutive  peritonitis  is  not  the  simple  one  that  it  at  first  sight 
appears. 

It  is  not  many  years  since  Bacterium  coli  commune  was  looked 
upon  merely  as  an  innocuous  inhabitant  of  the  intestine — as  an 
organism  devoid  of  pathogenetic  properties.  Its  detection  in  pure 
culture,  however,  in  many  cases  of  peritonitis,  as  well  as  in  morbid 
conditions  of  other  intra-abdominal  organs,  directed  attention  to 
the  possibility  of  it  possessing  pathogenetic  attributes.  Finally, 
the  determination  that  Bacterium  coli  commune  isolated  from  the 
intestine  in  case  of  disease  of  that  structure  is  more  virulent  than 
that  secured  from  the  normal  intestine,  and  the  experimental  pro- 
duction of  peritonitis  by  the  introduction  of  cultures  of  this  organism 
into  the  peritoneal  cavity  of  lower  animals,  definitely  proved  its 
pathogenetic  properties. 

Investigations  of  recent  years  have  conclusively  demonstrated 
not  only  that  Bacterium  coli  commune  is  variable  in  pathogenetic 
properties — that  is,  in  virulence — but  also  that  it  exhibits  other 
biological  and  morphological  differences,  such  as  of  size,  shape, 
motility,  etc.  It  suffices  to  mention  that  its  variation  in  size  is  well 
known;  that  some  cultures  are  much  more  actively  motile  than 
others;  that  Adami  has  recently  described  a  diplococcus  form;  and 
that  the  organisms  described  as  Bacillus  pyogenes  foetidus  (P asset). 
Bacillus  lactis  aerogenes  (Escherich),  Bacillus  neapolitanus  (Em- 
merich), Bacillus  enteritidis  (Gartner),  the  pyogenic  urinary  bacillus 
of  Clado  and  Albarran,  etc.,  are  most  likely  but  varieties  of  a  class 
of  bacteria  most  appropriately  designated  the  "colon  group." 
These  exhibit  quantitative  differences  in  their  biological  charac- 
teristics, but  it  is  questionable  if  they  do  so  to  a  degree  sufficient  to 
warrant  their  separation  into  distinct  species. 

When  Bacterium  coli  commune  was  found  in  the  peritoneal 
cavity,  and  in  the  exudate  upon  the  serous  coat  of  the  intestine,  in 


Pathology  149 

the  absence  of  perforation  of  that  structure — as,  for  instance,  in 
so-called  idiopathic  peritonitis,  strangulated  hernia,  volvulus,  etc. — 
the  relations  of  this  organism  to  the  intestinal  wall  and  vice  versa 
demanded  study.  That  which  particularly  required  elucidation 
was  the  question  whether  this  micro-organism  possesses  the  power 
to  penetrate  the  wall  of  the  intestine.  As  a  consequence  of  inves- 
tigation it  has  been  determined  that  this  bacterium  does  possess  the 
power  to  penetrate  the  wall  of  the  intestine,  although  the  normal 
intestine,  particularly  its  mucous  membrane,  opposes  effectually  a 
barrier  to  the  bacterium  of  ordinary  virulence.  If,  however,  the 
bowel  be  reduced  in  resistance — as  occurs  in  congestions,  inflam- 
mations, etc. — the  bacterium  penetrates  the  wall  with  more  or  less 
facility.  It  is  most  certain,  also,  that  the  toxin  elaborated  by 
virulent  Bacteria  coli  communia  retained  within  a  restricted  portion 
of  the  bowel  may  so  alter  the  mucous  membrane  as  to  permit  of 
invasion  of  the  wall.  This,  without  a  doubt,  occurs  in  such  an 
anatomical  tube  as  the  appendix. 

We  have  thus  come  to  view  Bacterium  coli  commune  as  a  group 
of  bacteria  rather  than  as  a  single  species.  The  individual  species 
have  been  described  under  a  variety  of  names,  and  exhibit  quanti- 
tative differences  in  their  biological  properties.  These  bacteria  are 
normal  in  all  portions  of  the  intestinal  tract  where  they  appear  a 
few  hours  after  birth.  They  are  probably  directly  or  indirectly 
concerned  in  the  processes  of  digestion.  Ordinarily,  they  are  but 
slightly  virulent,  or  they  may  be  innocuous.  Under  a  variety  of 
circumstances,  however,  they  become  greatly  increased  in  virulence, 
and  their  toxin  may  acquire  very  high  potentiality.  This  aug- 
mentation of  virulence  occurs  in  a  number  of  diseased  states,  such 
as  obstruction,  strangulation,  volvulus,  congestion,  oedema,  and 
inflammation  of  the  bowel;  in  various  diarrhoeic  conditions,  such 
as  that  which  follows  the  administration  of  purgatives,  typhoid 
fever,  cholera,  etc.;  and  in  marked  and  long-continued  constipa- 
tion. This  heightened  virulence  may  be  due  to  the  association 
with  Bacterium  coli  commune  of  other  bacteria,  but  under  some 
circumstances  it  seems  to  be  due  to  alterations  of  the  bowel  alone. 

That  Bacterium  coli  commune  is  not  the  only  micro-organism 
concerned  in  the  pathogenesis  of  appendicitis  is  sufficiently  evident 
from  the  foregoing  statistics  and  from  the  investigations  of  other 


150  Appendicitis 

observers.  Tavel  and  Lanz  first  directed  attention  to  the  frequent 
implication  of  several  forms  of  bacteria  in  the  production  of  appen- 
dicitis, and  these  authors  were  soon  followed  by  Barbacci,  and  since 
then  by  others,  among  whom  may  be  mentioned  Welch  and  others 
in  this  country.  It  has  been  contended  by  these  observers  that 
appendicitis  is  the  consequence  of  a  mixed  infection;  that  it  rarely 
results  from  a  mono-infection.  The  fact  that  Bacterium  coli  com- 
mune alone  is  usually  isolated  from  cultures  of  the  pus  from  cases  of 
appendicitis  is  explained  by  stating  that  Bacterium  coli  commune 
proliferates  much  more  luxuriantly  than  do  the  other  bacteria 
present,  and  thus  outgrows  them. 

In  but  33  of  the  286  cases  examined  was  such  mixed  infection 
demonstrated  by  the  methods  of  investigation  pursued.  These 
comprised  24  acute  cases  (18.75  P^^  cent.)  and  9  chronic  cases 
(5.7  per  cent.).  It  should  be  mentioned  here  that  in  those  instances 
in  which  cover-slip  preparations  of  the  contents  of  the  appendix 
and  of  the  peri-appendicular  exudate  and  pus  were  examined  the 
results  of  the  examination  did  not  differ  from  the  results  obtained 
by  culture  methods.  Cocci,  in  particular,  were  conspicuous  by 
their  absence.  In  this  respect  my  own  investigations  are  somewhat 
at  variance  with  those  of  other  observers.  While  free  to  admit 
that  the  systematic  examination  of  such  cover-slip  preparations 
in  all  cases  of  appendicitis  might  lead  to  the  detection  of  the  asso- 
ciated presence  of  two  or  more  varieties  of  bacteria  in  a  larger 
number  of  cases  than  my  statistics  indicate,  I  am  nevertheless  con- 
fident that  Bacterium  coli  commune  takes  by  far  the  greatest  part 
in  the  bacterial  origin  of  appendicitis. 

I  have  repeatedly  observed  that  if  the  cover-slip  preparations 
be  made  from  the  contents  of  the  appendix  at  a  point  somewhat 
removed  from  the  seat  of  most  manifest  disease,  a  great  variety  of 
bacteria  will  often  be  disclosed.  In  the  same  case,  however,  prepa- 
rations from  the  seat  of  more  advanced  disease,  or  from  the  peri- 
toneal exudate  or  pus,  will  disclose  only  a  bacillus  morphologically 
identical  with  Bacterium  coli  commune.  In  a  few  cases  cocci  also 
were  detected,  but  not  in  a  greater  proportion  of  cases  than  is  indi- 
cated by  the  statistics  as  previously  cited.  I  am  inclined  to  con- 
sider the  contaminating  organisms  in  the  first-mentioned  instances 
as  more  or  less  innocuous,  non-pathogenic,  intestinal  bacteria. 


Pathology  151 

I  have  also  taken  opportunity  to  examine  sections  from  a  number 
of  acutely  inflamed  appendices  for  the  presence  of  bacteria  in  the 
various  coats  of  the  wall  of  the  organ.  The  organisms  that  it  was 
possible  to  identify  were  almost  exclusively  such  as  were  morpho- 
logically similar  to  Bacterium  coli  commune.  In  exceptional  cases 
some  cocci  were  also  seen.  The  micro-organisms  were  commonly 
within  the  lymph  spaces,  and  were  often  some  distance  in  advance 
of  the  cellular  alterations.  Of  course,  I  am  not  unmindful  of  the 
fact  that  such  evidence  with  reference  to  the  identity  of  bacilli  must 
be  accepted  with  great  reservation.  It  is  extremely  suggestive, 
however,  that  cocci  were  so  regularly  conspicuous  by  their  absence, 
and  that  Bacterium  coli  commune  was  equally  conspicuous  by  its 
presence — not  only  in  cover-slip  preparations  made  from  the  intra- 
appendicular  pus,  extra-appendicular  exudate,  and  pus,  but  also 
in  the  respective  cultures  and  in  the  wall  of  the  appendix. 

Of  the  extreme  virulence  of  Bacterium  coli  commune  under 
certain  conditions  sufficient  experimental  and  clinical  evidence 
has  been  accumulated.  When  to  this  we  add  the  fact  that  the 
conditions  in  the  appendix  are  most  favorable  for  the  sudden 
and  rapid  increase  in  the  virulence  of  a  bacterium  that  may  be 
innocuous,  or  almost  so,  in  other  portions  of  the  intestinal  tract,  it 
seems  to  me  that  the  predominating  importance  of  this  organism 
in  the  aetiology  of  appendicitis  cannot  be  gainsaid.  It  cannot  be 
denied  that  Bacterium  coli  commune,  under  suitable  conditions, 
proliferates  most  luxuriantly  in  culture  media.  Nor,  on  the  other 
hand,  can  it  be  denied  that  the  appendix  is  a  most  appropriate 
test-tube,  and  that  the  contents  of  the  appendix  are  most  suitable 
media  in  which  to  cultivate  a  virulent  growth  of  Bacterium  coli 
commune.  I  believe,  therefore,  that  as  this  organism  outgrows 
other  bacteria  in  artificial  media,  so  also  does  it,  under  suitable 
conditions,  assume  a  predominance  in  the  appendix.  This  organ 
like  the  intestine,  under  normal  circumstances  contains  a  variety 
of  bacteria;  but  under  conditions  favorable  for  the  development 
of  appendicitis,  particularly  when  the  lumen  of  the  appendix 
becomes  occluded.  Bacterium  coli  commune  rapidly  becomes  the 
predominating  and  most  virulent  organism. 

These  statements  naturally  do  not  eliminate  from  consideration 
other  bacteria  as  aetiological  factors  in  inflammatory  affections  of 


152  Appendicitis 

the  appendix.  A  number  of  other  micro-organisms  have  been 
found  sufficiently  often  by  different  observers,  as  well  as  by  myself, 
and  their  virulence  has  been  repeatedly  tested,  to  indicate  their 
importance  in  the  production  of  appendicitis.  Interest  is  attached 
to  the  presence  of  Bacillus  pyocyaneus  in  six  of  my  cases  of  acute 
appendicitis  and  in  two  of  the  cases  of  chronic  appendicitis.  The 
pathogenetic  importance  of  the  streptococcus,  when  present,  cannot 
be  overestimated,  and  the  same  is  also  true  of  the  staphylococci.. 
I  have  attempted  to  verify  the  findings  of  Dudgeon  and  Sargent, 
as  to  the  uniform  occurrence  of  staphylococcus  albus  in  the  early 
stages  of  appendicular  peritonitis  and  my  results  are  altogether  at 
variance  from  those  obtained  by  these  observers.  The  recent  work 
of  Hyde  on  the  anaerobic  organisms  draws  attention  to  several 
interesting  points  in  connection  with  this  group  of  the  intestinal 
flora.  He  claims  to  find  anaerobes  predominating  in  the  tissues 
at  the  margin  of  advancing  peritonitis,  also  he  finds  certain  an- 
aerobes which  can  cause  direct  necrosis  with  decomposition  and 
holds  this  type  of  organism  responsible  for  the  severe,  toxic,  clinical 
picture  so  often  seen  in  appendicitis.  Hyde  adduces  experimental 
proof  of  the  heightened  activity  of  both  anaerobes  and  aerobes  under 
condition  of  symbiosis  and  therefore  attaches  clinical  importance 
to  differences  in  diet  which  would  be  expected  to  cause  differences 
in  the  bacteriology  of  appendicitis.  It  is  quite  possible  that  the 
occasional  apparent  contagiousness  of  appendicitis,  its  occurrence  in 
families,  and  the  marked  absence  of  it  among  the  Chinese,  may 
depend  upon  such  peculiarities  in  diet.  Of  other  bacteria  encount- 
ered in  appendicitis  the  following  may  be  mentioned :  Varieties  of 
proteus.  Bacillus  subtilis.  Bacillus  capsulatus.  Coccus  conglomera- 
tus.  Bacillus  fusiformis,  bacilli  resembling  those  of  diphtheria, 
glanders,  tetanus,  actinomycosis,  etc.,  and  the  pneumococcus,  etc. 
The  last-named  organism  was  isolated  by  Barbacci  from  60  per 
cent,  of  his  cases,  but  I  have  not  encountered  it. 

Undoubtedly,  in  certain  cases  bacteria  other  than  Bacterium 
coli  commune  do  contribute  to  cause  appendicitis;  in  some  cases 
they  are  doubtless  the  sole  aetiological  factor.  This  is  indicated  by 
the  fact  that  in  certain  of  my  own  cases,  as  well  as  in  those  of  other 
observers,  this  bacterium  was  absent,  whereas  other  micro-organisms 
were  present.     It  has  been  stated  that  undue  prominence  is  assumed 


Pathology  153 

by  Bacterium  coli  commune  because  of  the  property  it  possesses  of 
invading  tissues  aheacly  the  seat  of  morbid  aUerations  inaugurated 
by  other  organisms.  The  latter,  following  invasion  by  Bacterium 
coli  commune,  are  believed  to  assume  a  subsidiary  role,  and  to 
become  overshadowed  by  reason  of  the  active  proliferation  of  the 
invaders.  Personally,  I  am  inclined  to  accord  predominance  to 
that  organism  which,  it  is  believed,  so  readily  overcomes  such  well- 
known  and  virulent  bacteria  as  the  streptococci,  etc.,  rather  than 
believe  that  other  organisms  inaugurate  the  morbid  condition  in 
the  appendix  and  then  succumb  to  the  activities  of  Bacterium  coli 
commune.  I  believe  that  conditions  are  analogous  in  the  appendix 
and  in  the  test-tube;  and  that,  further,  as  most  of  my  examinations 
of  acute  cases  were  made  very  early  in  the  attack,  if  bacteria  other 
than  Bacterium  coli  commune  were  so  frequently  concerned  in  the 
aetiology  of  appendicitis,  as  is  held  by  some,  they  would  have  been 
detected  by  the  methods  of  investigation  pursued. 

As  will  appear  later,  the  most  important  factor  in  the  augmenta- 
tion of  the  virulence  of  Bacterium  coli  commune  in  the  appendix 
is  defective  drainage.  When  the  drainage  of  the  appendix  becomes 
impeded  or  ceases  entirely.  Bacterium  coli  commune  rapidly  multi- 
plies and  increases  in  virulence,  producing  a  toxin  of  very  high 
potentiality.  This,  either  alone  or  associated  with  the  products  of 
decomposition  of  the  appendicular  contents,  suflSices  to  inaugurate 
catarrhal  alterations  in  the  appendix.  As  a  consequence  of  this, 
and  also  of  the  mechanical  pressure  exerted  by  the  accumulating 
secretion,  the  mucous  membrane  becomes  reduced  in  vitality,  and 
invasion  of  the  wall  of  the  organ  is  a  matter  easy  of  accomplish- 
ment. The  bacteria  may  successively  invade  each  coat  of  the 
appendix  until  they  reach  the  serous  coat.  Here  they  may  give 
rise  to  a  peritonitis,  which  may  become  suppurative,  and  may  be 
either  circumscribed  or  diffuse.  It  is  thus  that  peri-appendicular 
suppuration  arises  in  the  absence  of  perforation  of  the  appendix. 
As  the  bacteria  penetrate  deeper  into  the  wall  of  the  appendix,  they 
commonly  liquefy  the  tissues  by  peptonizing  them,  and,  as  a  matter 
of  fact,  most  cases  of  appendicitis  with  appendicular  peritonitis 
present  more  or  less  ulceration  of  the  appendix.  In  some  cases  the 
toxin  elaborated  is  excessively  virulent  (and  some  of  these  are 
doubtless  streptococcic),  and  there  is  widespread  disease  of  the 


1 54  Appendicitis 

appendix,  possibly  gangrene,  with  virulent  peritonitis,  and  still  no 
perforation  of  the  appendix.  There  thus  can  be  no  question  that 
bacteria  alone  are  amply  capable  of  exciting  appendicitis;  that  such 
appendicitis  may  be  attended  by  ulceration  in  the  absence  of  appen- 
dicular calculi;  and  that  suppurative  peritonitis  may  be  associated 
with  appendicitis  without  perforation  of  the  appendix. 

The  differences  in  the  severity  of  the  clinical  manifestations  of 
cases  of  appendicitis  are  explicable  upon  the  assumption  of  varia- 
tions in  the  virulence  of  the  toxins  elaborated  by  the  bacteria 
provocative  of  the  inflammatory  attack.  In  some  cases  it  is  likely 
that  two  or  more  varieties  of  bacteria  acting  in  symbiosis  produce  a 
much  more  virulent  composite  toxin  than  would  either  alone. 
The  leucocytes  and  nuclein  are  defenses  provided  by  nature,  but 
they  are  often  ineffectual.  The  absorption  of  the  toxins  engenders 
the  various  general  manifestations  of  the  disease,  of  which  the  most 
important  are  albuminuria  with  casts;  urobilinuria;  indicanuria; 
a  peculiar  icteric  tint  of  the  skin;  disturbances  of  cerebration,  of 
cardiac  action,  etc.  It  is  a  peculiarity  of  the  toxin  of  some  cases 
which  develop  insidiously  that  it  gives  rise  to  symptoms  which,  for 
a  time  at  least,  much  resemble  those  of  typhoid  fever. 

THE  PATHOGENESIS/ 

In  considering  the  pathogenesis  of  appendicitis  it  must  be  borne 
in  mind  that  inflammation  of  the  vermiform  appendix  is  in  many 
respects  so  unique  a  disease;  it  differs  so  materially  from  inflamma- 
tory affections  of  other  portions  of  the  gastro-intestinal  tract;  it  is 
often  so  sudden  in  its  onset,  so  alarming  in  its  aspects,  and  so  dis- 
astrous in  its  consequences,  that  it  behooves  us  to  look  for  some  cause 
or  causes  resident  in  or  about  the  appendix  itself  to  account  for  the 
much  greater  frequency  of  inflammation  of  this  portion  as  compared 
with  other  portions  of  the  gastro-intestinal  tract,  and  for  the  pre- 
ponderating role  such  inflammation  plays  in  the  aetiology  of  peri- 
tonitis. As  a  matter  of  fact,  there  pertain  to  the  appendix  certain 
important  anatomical  and  physiological  peculiarities  that  must  of 
necessity  exert  considerable  influence  in  the  production  of  diseased 

'Consult:  Kelly,  A.  O.  J.,  "The  Pathogenesis  of  Appendicitis,"  Philadelphia 
Medical  Journal,  iv,  pp.  928,  983,  and  1032,  1899. 


Pathology  155 

conditions  of  that  organ — that  act  as  predisposing  causes.  The 
most  important  of  these  are:  (i)  The  shape  of  the  meso-appendix; 
(2)  the  excessive  length  as  compared  with  the  width  of  the  appen- 
dix; (3)  Gerlach's  valve;  (4)  the  histological  structure  of  the  organ; 
(5)  the  blood  supply;  (6)  the  nerve  supply;  (7)  the  evidences  of  in- 
volution of  the  organ. 

The  meso-appendix  is  of  importance  for  several  reasons.  It 
not  only  acts  as  a  predisposing  factor  in  the  causation  of  inflam- 
mation of  the  appendix,  but  it  also  has  important  bearings  with 
reference  to  the  possible  results  of  such  inflammation.  The  relations 
of  the  appendix  to  the  peritoneum  and  vice  versa  are  various.  As  a 
rule,  the  appendix  is  completely  enveloped  by  a  fold  of  peritoneum 
and  lies  free  within  the  peritoneal  cavity — it  is  an  intra-peritoneal 
organ.  Exceptionally,  however,  its  posterior  surface  is  unprovided 
with  a  peritoneal  covering.  Under  such  circumstances  the  organ 
is  in  direct  association  with  the  retro-peritoneal  connective  tissue, 
and  this  relation  is  of  importance  as  influencing  the  course  of  pos- 
sible peri-appendicular  suppuration.  Commonly,  however,  as  al- 
ready stated,  it  lies  free  in  the  peritoneal  cavity  and  is  almost  in- 
variably provided  with  a  meso-appendix.  The  latter  is  usually  tri- 
angular in  shape,  though  it  varies  considerably  in  size,  in  thickness, 
and  in  the  extent  to  which  it  is  attached  to  the  appendix.  In  the 
majority  of  instances  the  meso-appendix  extends  the  entire  length  of 
the  appendix.  Exceptionally,  however,  the  tip  of  the  organ  may 
be  free;  and  more  rarely,  the  meso-appendix  may  be  attached  to 
but  the  proximal  two-thirds  or  one-third  of  the  organ.  It  is,  how- 
ever, because  of  its  size  that  the  meso-appendix  bears  an  important 
aetiological  relationship  to  appendicitis.  If  it  have  a  breadth  com- 
mensurate with  its  length,  or  if  it  be  very  short  or  entirely  absent, 
as  far  as  the  meso-appendix  is  concerned,  the  appendix  will  be  quite 
straight.  If,  however,  it  be  relatively  narrow  as  compared  with  its 
length,  the  appendix  will  be  correspondingly  curved  or  distorted. 
Under  such  circumstances,  depending  upon  the  degree  of  the  curve, 
flexure,  or  distortion,  the  free  drainage  of  the  appendix,  so  essential 
to  its  well-being,  is  compromised.  As  will  be  detailed  later,  when 
the  free  and  thorough  drainage  of  the  organ  is  interfered  with,  one 
of  the  most  important  aetiological  factors  of  appendicitis  becomes 
operative. 


156  Appendicitis 

The  excessive  length  of  the  appendix  as  compared  with  its 
width,  and  more  particularly  with  the  calibre  of  its  lumen,  is  another 
important  aetiological  factor  in  appendicitis,  and  this  also  because 
of  the  interference  thereby  engendered  with  thorough  drainage. 
Appendices  vary  considerably  in  length,  some  being  very  short, 
others  very  long.  The  longest  that  I  have  encountered  was  14  cm. 
The  average  length  is  from  8  cm.  to  9  cm.  On  the  other  hand,  the 
diameter  of  the  lumen  of  appendices  that  appear  not  to  have  been 
diseased  varies  between  3  mm.  and  5  mm,,  and  there  are  often 
marked  dififerences  at  different  levels  of  the  same  organ.  The  re- 
lation, then,  of  the  diameter  of  the  lumen  to  the  length  of  the  appen- 
dix is  about  as  i  to  16  or  25 — an  evident  disproportion,  to  which 
must  be  ascribed  considerable  pathogenetic  significance.  It  ap- 
pears that  if  the  appendix  once  becomes  the  seat  of  disease,  this 
disproportion  is  much  accentuated.  Thus,  in  over  75  per  cent,  of 
appendices  the  seat  of  chronic  inflammation  that  were  examined  the 
lumen  had  been  reduced  in  diameter  to  2  mm.  or  less  throughout. 
In  a  number  of  the  remaining  25  per  cent.,  the  lumen  was  but  2  mm. 
at  certain  levels,  but  exceeded  this  at  others.  Of  those  in  which  the 
diameter  of  the  lumen  was  2mm.  or  less  throughout,  it  was  in  many 
places  I  mm.  or  less.  The  pathogenetic  significance  of  this  dispro- 
portion between  the  calibre  of  the  lumens  and  the  length  of 
appendices  apparently  healthy  becomes  much  augmented  if  for  any 
reason  the  lumen  be  diminished,  as  by  chronic  inflammation  or 
otherwise. 

The  exact  significance  to  be  attached  to  Gerlach's  valve  is 
indeterminate,  and  this  largely  because  that  structure  itself  is  very 
indeterminate.  It  is  usually  e\'ident,  when  the  caecum  is  viewed 
from  within,  as  a  small  prominence  of  the  mucous  membrane  sur- 
rounding, either  completely  or  in  part,  the  orifice  of  the  appendix. 
Upon  close  inspection  it  is  seen  to  be  made  up  of  a  reduplication  of 
the  mucous  membrane,  and  microscopical  examination  reveals,  in 
addition,  some  lymphoid  tissue.  It  is  better  developed  in  youth  than 
in  old  age.  It  is  said  to  be  most  marked  in  infants  during  the  first  year 
of  life;  in  adults  and  the  aged  it  often  eludes  detection  by  the  unaided 
eye.  Microscopical  examination,  however,  usually  reveals  some  indi- 
cation of  it.  Krafft  states  that  Nanninga  has  observed  immediately 
below  this  valve  a  second  smaller  one.     At  all  events  the  valve  is 


Pathology  157 

admittedly  a  rather  inconstant  structure.  Nevertheless,  it  can 
readily  be  surmised  that  when  present  it  serves  to  retard  the  en- 
trance into  the  appendix  of  intestinal  contents,  and  to  hinder, 
possibly  to  a  less  degree,  the  escape  into  the  caecum  of  appendicular 
contents.  It  is  this  latter  function  that  is  the  more  important  in  this 
connection.  If  for  any  reason  the  region  of  the  cascum  about  the 
appendicular  orifice,  or  Gerlach's  valve,  becomes  swollen,  the  escape 
of  appendicular  contents  is  more  effectually  prevented,  defective 
drainage  ensues,  and  appendicitis  results. 

The  histological  structure  of  the  appendix  has  important 
bearings  upon  the  pathogenesis  of  inflammation  of  the  organ. 
It  is  quite  correct  to  state  that  in  general  the  appendix  conforms  in 
histological  architecture  to  the  structure  of  the  large  intestine,  but 
it  is,  nevertheless,  very  unwise  to  lose  sight  of  the  many  particulars 
in  which  it  presents  deviations  from  that  type.  That  which  is  es- 
pecially the  most  important  is  the  presence  in  the  mucous  membrane 
of  the  appendix  of  a  considerable  amount  of  lymphoid  tissue.  These 
lymphoid  cells  at  times  infiltrate  without  definite  arrangement  the 
mucosa;  at  times  they  are  collected  into  definite  groups  that  are 
spoken  of  as  lymphoid  follicles.  It  is  because  of  this  richness  in 
lymphoid  tissue  that  the  appendix  has  been  aptly  compared  to  the 
tonsil.  It  has  been  spoken  of  as  the  "abdominal  tonsil,"  and  com- 
parison has  been  made  between  cases  of  "simple  tonsillitis"  and 
"simple  appendicitis"  (which  Sahli  even  speaks  of  as  "angina  of 
the  appendix") — both  of  which  are  considered  by  some  amenable  to 
medicinal  treatment — and  between  suppuration  of  the  tonsil  and 
suppuration  or  sloughing  of  the  appendix. 

The  amount  of  lymphoid  tissue  in  the  appendix  seems  to  bear 
some  relation  to  the  age  of  the  individual,  and  this  may  not  be  with- 
out significance  in  the  aetiology  of  inflammation  of  that  organ.  My 
investigations,  which  have  been  so  largely  with  diseased  appendices, 
hardly  warrant  me  in  formulating  a  positive  opinion  on  this  subject; 
they  have,  however,  led  me  to  believe,  with  Ribbert  and  Kelynack, 
that  lymphoid  elements  are  more  abundant  in  the  appendix  during 
childhood  than  during  later  life. 

Berry  and  Lack  have  made  very  full  and  apparently  conclusive 
studies  upon  the  histological  structure  of  the  appendix  and  especially 
of  its  lymphoid  tissue.     They  state  that  its  formation  does  not  begin 


158  Appendicitis 

until  one  to  six  weeks  after  birth  there  being  practically  none  in  the 
appendix  of  the  full  term  fcetus.  At  thirty-two  weeks  the  lymphoid 
tissue  acts  as  an  actively  functionating  gland. 

The  lymphoid  tissue  seldom  totally  disappears  but  is  present  in 
great  amounts  in  early  life  and  shows  a  progressive  tendency  to 
disappear.  They  tabulate  the  average  number  of  lymphoid 
follicles  present  in  a  single  transverse  section  through  the  centre  of 
the  human  appendix,  as  follows: 

Below  I  year . .  5 

I  to  10  years 6 

ID  to  20  years .-  .  .  7 

20  to  30  years 6 

30  to  40  years 3 

40  to  50  years 3 

50  to  60  years • 2 

60  to  70  years trace  only. 

70  to  80  years practically  none. 

Very  obvious  changes  do  not  take  place  until  the  age  of  about  thirty. 
Then  the  lymph  follicles  show  a  tendency  to  become  flattened  and 
diffuse  while  the  mucosa  commences  to  show  signs  of  atrophy. 
They  conclude  that  until  the  fourth  decade  the  appendix  is  an 
actively  functionating  gland. 

It  is  well  known  that  affections  of  adenoid  tissue  are  more 
likely  to  occur  in  the  young  than  in  the  aged,  and  in  some  cases  of 
appendicitis  this  fact  is  probably  of  aetiological  importance — appen- 
dicitis being  pre-eminently  a  disease  of  adolescence  and  early  adult 
life.  Ribbert  states  that  the  typical  arrangement  of  the  lymphoid 
elements  into  foUicles  is  preserved  until  about  the  thirtieth  year, 
when  the  follicles  commence  to  undergo  some  atrophy  and  become 
more  widely  separated.  Exceptionally,  this  physiological  atrophic 
process  may  be  installed  as  early  as  the  twentieth  year.  Ribbert 
and  Kelynack,  nevertheless,  state  that  lymphoid  tissue  may  be 
found  in  the  appendices  of  the  aged,  and  my  own  investigations 
certainly  confirm  this  \iew.  Ribbert  mentions,  also,  that  in  the 
rabbit,  more  so  than  in  man,  the  appendix  is  characterized  histolog- 
ically by  the  presence  of  such  an  amount  of  lymphoid  tissue  as  to 
make  it  resemble  a  single  large  Peyer's  patch.  Hawkins,  on  the 
other  hand,  is  reservedly  inclined  to  believe  that  the  amount  of 
lymphoid  tissue  in  the  appendix  does  not  bear  any  direct  relation- 


Pathology  159 

ship  to  the  age  of  the  individual,  but  states  that  only  the  examination 
of  a  large  number  of  normal  appendices  would  warrant  any  definite 
statements  on  this  subject.  It  is  reasonable,  also,  to  assume  that 
those  the  subjects  of  the  "lymphoid  diathesis"  are  rather  prone  to 
appendicitis,  as  to  affections  of  adenoid  tissue  in  general,  and  in 
this  connection  the  operations  of  heredity  may  not  be  without 
significance. 

Another  histological  peculiarity  of  the  appendix  of  considerable 
significance  is  the  relatively  extensive  epithelial  surface  that  it 
presents — extensive  as  compared  with  the  size  of  the  appendix. 
Under  circumstances  of  even  slight  irritation  or  erosion  it  thus  affords 
a  large  surface  for  the  absorption  of  the  noxious  products  of  bacteria. 
This  is  further  increased  by  the  numerous  crypts  of  Lieberkiihn 
wherein  the  bacteria  become  lodged  and  continuously  produce 
their  toxins. 

The  blood  supply  of  the  appendix  and  the  pathogenetic 
relationship  that  the  blood-vessels  and  the  arterial  supply  bear 
to  inflammation  of  that  organ  have  been  considerably  studied.  It 
is  unnecessary  here  to  go  into  a  detailed  description  of  the  blood  sup- 
ply of  the  appendix,  but  some  sHght  reference  to  the  blood-vessels 
themselves  may  be  opportune.  If  I  mistake  not,  it  was  Fowler  and 
Van  Cott  who  first  directed  particular  attention  to  the  important 
aetiological  role  of  the  circulatory  apparatus  of  the  appendix  in 
inflammation  of  that  organ.  These  authors  believe  that  the  appendix 
is  peculiarly  exposed  to  vascular  and  nervous,  and  hence  to  nutri- 
tional, disturbances,  and  base  their  opinion  upon  an  examination 
of  thirteen  appendices  made  by  Van  Cott.  The  examination  of 
these  is  said  to  have  revealed  in  the  vessels  of  the  meso-appendix 
some  form  or  other  of  obstruction  to  the  blood  current,  either 
paravasculitis,  perivasculitis,  or  endovasculitis;  and  these,  it  is 
believed,  must  have  preceded  the  intense  round-cell  infiltration, 
the  coagulation  necrosis,  the  purulent  foci,  that  they  detected  in  the 
walls  of  the  appendices.  Van  Cott  also  states  that  in  several  cases  he 
found  a  distinct  chronic  interstitial  neuritis  with  extensive  atrophy  of 
the  nerve  fibres  resulting  from  hyperplasia  of  the  endoneurium  and 
perineurium.  He  argues  from  these  that  the  real  cause  of  the  locus 
minoris  resistenticB  admitting  of  bacterial  invasion  is  not  to  be  sought 
in  a  trauma  of  the  mucosa,  but  in  a  trophic  disturbance  of  the  appen- 


i6o  Appendicitis 

dix,  the  result  of  chronic  vascular  lesion  or  of  chronic  nerve  lesion, 
or  both;  and  that  the  ulcerative  processes  in  the  appendix,  while 
they  may  be  increased  by  bacterial  invasion,  may  nevertheless 
owe  their  origin  to  these  trophic  conditions. 

These  opinions  have  been  subjected  to  critical  investigation  and 
have  commonly  not  been  confirmed.  In  particular,  Breuer,  at  the 
instigation  of  Nothnagel,  carefully  examined  thirty  appendices, 
some  of  which  had  been  removed  at  necropsy  and  some  at  opera- 
tion, among  the  latter  there  being  instances  of  acute  and  chronic 
appendicitis.  By  means  of  carefully  performed  injection  of  the 
arteries,  he  first  of  all  determined  that  the  vascular  supply  of  the  ap- 
pendix is  not  a  terminal  one,  such  as  obtains  in  the  brain,  spleen, 
kidney,  etc.,  but  that  a  not  inconsiderable  collateral  blood  supply 
comes  from  the  adjoining  caecal  vascular  area.  Furthermore,  it 
was  determined  that  these  anastomosing  arterial  branches  course 
partly  beneath  the  mucosa,  partly  in  the  muscularis,  and  partly 
directly  beneath  the  serosa.  But  as  the  pertinent  result  of  his  in- 
vestigations, Breuer  was  unable  to  detect  vascular  alterations  of  the 
constancy  and  extent  described  by  Van  Cott.  In  cases  of  chronic 
inflammation  of  the  appendix  the  larger  arteries  of  the  meso-ap- 
pendix  were  regularly  intact,  even  when  surrounded  by  hyperplastic 
connective  tissue.  Not  only  this,  but  the  smaller  vessels — the  arter- 
ies and  veins — of  various  regions  of  the  wall  of  the  appendix 
revealed  but  rarely  pathological  alterations.  For  instance,  in  areas 
in  which  the  entire  mucous  membrane  was  converted  into  cicatricial 
connective  tissue  there  were  evident  but  slight  thickening  of  the  ves- 
sels, endothelial  proliferation,  etc.— changes  that,  it  is  asserted, 
are  detectable  in  every  cicatricial  tissue  and  in  instances  of  normal 
involution  of  the  appendix.  In  cases  of  acute  suppurative  ap- 
pendicitis the  alterations  of  the  vessels  were  more  common,  but 
they  were  limited  to  the  acutely  inflamed  region  and  its  immediate 
vicinity.  As  the  result  of  my  own  investigations,  I  believe  there 
can  be  no  question  that  Van  Cott  is  correct  in  asserting  that  these 
vascular  alterations  are  present  in  some  presumably  normal  and  in 
some  diseased  appendices,  but  I  also  believe  that  he  erroneously 
interprets  their  significance  and  overestimates  their  importance. 

In  a  considerable  number  of  presumably  normal  appendices  re- 
moved at  necropsy  and  subjected  to  histological  investigation  the  thick- 


Pathology  i6i 

ness  of  the  vessel  wall  of  the  appendix,  as  well  as  of  the  meso-appendix, 
impressed  me  forcibly.  In  many  of  these  the  deviations  from  the 
normal  were  almost  exclusively  confined  to  the  muscular  coat.  In 
not  a  few  instances,  however,  there  was  a  distinct  proliferation  of  the 
intima.  The  vessel  walls  of  the  remaining  appendices  appeared 
entirely  normal.  Pathological  alterations,  particularly  endothelial 
proliferation,  were  more  common  in  the  diseased  appendices  exam- 
ined. In  some  of  the  appendices  that  had  been  the  seat  of  recurring 
attacks  of  inflammation  the  thickening  of  the  vessel  walls  was  very 
apparent.  In  some  of  the  acute  cases  the  endothelial  proliferation 
was  equally  conspicuous.  In  other  appendices — those  which  for 
a  shorter  or  longer  time  had  been  the  seat  of  chronic  inflammation, 
and  which  had  more  recently  suffered  an  acute  exacerbation — 
alterations  of  both  the  media  and  intima  were  evident.  In  many  of 
the  acute  cases,  however,  the  vessel  walls  presented  no  noteworthy 
deviations  from  the  normal.  Some  interstitial  connective-tissue 
overgrowth  was  also  occasionally  detected  in  and  about  the  nerves 
of  the  meso-appendix,  but  by  no  means  so  regularly  and  constantly 
as  indicated  by  Van  Cott.  As  the  result,  therefore,  of  my  own  in- 
vestigations considerable  pathogenetic  significance  is  ascribed  to  the 
condition  of  the  arteries,  but  more  to  the  blood  supply.  I  believe 
that  cases  in  which  nerve  lesions  may  with  justice  be  held  accountable 
for  the  development  of  appendicitis  are  quite  exceptional.  How- 
ever, excluding  instances  of  thrombosis  and  embolism  of  the  chief 
appendicular  vessels  or  their  branches,  and  obstruction  of  the  blood 
supply  by  means  of  torsions,  angulations,  or  contracting  bands  of 
connective  tissue  compressing  the  vessels,  I  do  not  believe  that 
ulceration  of  the  wall  of  the  appendix  can  with  reason  be  ascribed 
to  arterial  alterations.  I  believe,  though,  that  the  precarious 
blood  supply  of  the  appendix  may  with  justice  be  held  at  least  partly 
accountable  for  the  disastrous  consequences  to  the  appendix  of 
causes  therein  provocative  of  inflammation,  but  which  in  other 
portions  of  the  intestinal  tract  remain  inoperative.  I  believe,  also, 
that  in  case  the  blood  supply  of  the  appendix  becomes  very  defective 
by  reason  of  torsions,  flexures,  etc.,  conditions  obtain  in  the  appendix 
that  render  the  common  exciting  causes  of  ulceration  very  prone 
to  produce  their  deleterious  effects.  And,  finally,  I  believe  that 
many  of  the  instances  of  proliferation  of  the  endothelium  of  the  vessels 


i62  Appendicitis 

of  diseased  appendices  are  to  be  interpreted  as  the  consequence, 
not  the  cause,  of  the  inflammation. 

The  indications  of  involution  of  the  appendix  demand  care- 
ful consideration,  and  the  proper  interpretation  of  suggestive  altera- 
tions is  frequently  a  matter  for  judicious  discrimination.  Particular 
investigation  of  this  question  has  been  made  by  Ribbert,  Zucker- 
kandl,  and  Piersol.  Ribbert  examined  400  appendices  obtained  at 
necropsy  and  determined  that  99  (25  per  cent.)  presented  evidences 
of  retrogressive  atrophic  alterations  without  indications  of  previous 
inflammation.  These  alterations  were,  theiefore,  interpreted  as 
evidences  of  involution.  Zuckerkandl  investigated  232  appendices, 
and  detected  in  55  evidences  of  obliteration  of  the  lumen — therefore 
in  23.7  per  cent.  Of  100  appendices  of  persons  over  twenty  years  of 
age  examined  by  Ribbert,  32  presented  these  evidences  of  retro- 
gression. The  obliteration  of  the  lumen  was  commonly  but  partial; 
it  was  complete  in  but  3.5  per  cent.  In  one-half  of  the  cases  the 
distal  quarter  was  closed;  in  one-half  of  the  remaining  cases  the 
obliteration  affected  between  one-fourth  and  three-fourths  ot  the 
entire  length  of  the  organ;  in  the  remaining  9  per  cent,  the  oblitera- 
tion was  but  partial. 

There  can  be  no  question  that  these  evidences  of  retrogression 
are  common.  In  the  presumably  normal  appendices  removed  at 
necropsy  that  I  examined  they  were  found  in  almost  one-fourth  of 
the  cases.  They  were  usually  confined  to  the  tip  of  the  organ, 
and  to  a  small  portion  of  it.  Exceptionally,  they  implicated  about 
one-fourth,  or  a  little  more,  of  the  entire  length  of  the  organ.  In 
these  cases  the  remainder  of  the  organ  presented  no  recognizable 
histological  deviations  from  the  normal.  These  indications  of  in- 
volution were  also  evident  in  appendices  manifestly  the  seat  of  in- 
flammatory disease,  and,  as  in  the  other  cases,  they  were  commonly 
limited  to  the  distal  end  of  the  organ.  In  no  case  did  they  implicate 
as  much  as  one-half  of  the  appendix.  In  all  these  cases,  however, 
the  inflammatory  character  of  the  associated  alterations  was  beyond 
question. 

The  exact  nature  of  these  involutionary  changes  is  still  more 
or  less  a  matter  of  conjecture.  Ribbert  states  that  in  appendices 
undergoing  these  alterations  three  zones  can  usually  be  recognized: 
(i)  A  central  zone  more  or  less  rich  in  cells;  (2)  a  zone  which  shows 


Pathology  163 

gradual  transition  from  the  first,  and  which  is  poor  in  cells  and 
made  up  largely  of  connective  tissue;  and  (3)  the  muscular  coat. 
The  first  or  inner  zone  corresponds  to  the  former  mucous  mem- 
brane; the  second  or  middle,  to  the  former  submucosa.  The  inner 
zone  at  times  reveals  a  small,  narrow  sHt,  indicative  of  the  former 
lumen.  Careful  examination  of  this,  however,  will  often  reveal  a 
few  strands  of  delicate  connective  tissue  traversing  it  from  side  to 
side.  These  are  readily  torn  and  are  likely  to  escape  detection. 
Ribbert  believes  that  the  symmetry  of  the  process,  its  progression 
from  the  distal  to  the  proximal  end  of  the  appendix,  and  the  absence 
of  irregularities,  of  cicatricial  tissue,  and  of  other  indications  of 
previous  inflammatory  conditions  justify  the  assumption  that  the 
process  is  involutionary  in  nature.  It  may  be  mentioned  that 
this  fact  is  indicated,  in  addition,  by  the  absence  of  degenerative 
alterations  in  the  mucous  membrane — the  change  being  rather  one 
of  gradual  atrophy.  I  believe,  with  Zuckerkandl,  that  the  sub- 
mucosa plays  a  most  important  role  in  these  alterations,  and  that 
the  changes  in  the  other  coats  follow  those  of  the  submucosa. 
Piersol  concurs  in  this  opinion,  stating  that  "changes  within  the 
submucosa  inaugurate  the  process  leading  to  the  retrogression  of 
the  appendix  and  precede  the  alterations  affecting  the  mucosa." 
Defective  nutritive  supply  is  doubtless  the  basis  of  the  process.  As 
regards  the  role  that  these  involutionary  changes  play  in  the  causa- 
tion of  appendicitis,  it  suffices  for  the  present  to  state  that  they  are 
to  be  considered  as  indicative  of  a  locus  minoris  resistentia,  which 
permits  of  the  more  ready  operation  in  the  appendix  than  in  other 
portions  of  the  intestinal  tract  of  the  exciting  causes  of  appendicitis. 

Berry  and  Lack  do  not  consider  obliteration  of  the  appendix  a 
physiological  process  because  it  occurs  at  all  periods  of  life  and  a 
progressive  examination  of  appendices  from  birth  to  the  most 
advanced  age  does  not  reveal  any  great  increase  in  the  tendency 
to  obliteration.  They  found  seven  instances  in  103  examinations 
and  each  was,  they  assert,  the  evidence  of  an  interstitial  fibrosis 
the  result  of  vascular  obstruction.  Aschoff  concludes  also  that 
obliteration  of  the  appendix  results  from  inflammation  and  is  not  a 
physiological  procedure. 

The  foregoing,  then,  are  the  factors  that  predispose  the  appen- 
dix to  attacks  of  inflammation.     They  acquire  their  pathogenetic 


164  Appendicitis 

significance  because  they  interfere  with  the  proper  and  thorough 
drainage  of  the  organ;  because  they  reduce  the  capabiHty  of  the 
organ  to.  resist  the  influences  of  various  morbific  agencies;  because 
of  the  facility  with  which  nutritional  disturbances  may  be  engen- 
dered; and  because  of  the  relatively  large  surface  presented  for  the 
absorption  of  the  toxic  products  of  bacteria  that  find  their  exit  from 
the  appendicular  lumen  retarded  or  prevented.  Bearing  in  mind 
these  facts,  when  we  institute  a  study  of  the  pathogenesis  of  appen- 
dicitis, it  is  immediately  patent  that  no  one  factor  alone  can  be  held 
accountable  for  the  development  of  all  cases  of  the  affection.  On 
the  contrary,  the  previously  mentioned  anatomical  and  physiological 
peculiarities  of  the  appendix  render  the  organ  less  resistant  to  the 
well-known  morbific  agencies  provocative  of  inflammation  in  other 
portions  of  the  body.  In  individual  instances  one  or  the  other  of 
these  peculiarities  predominates  over,  and  thus  assumes  a  patho- 
genetic significance  disproportionate  to,  the  others. 

The  exciting  causes  of  appendicitis  do  not  differ  from  those 
that  induce  inflammation  in  other  portions  of  the  body.  As  is 
well  known,  the  most  common  causes  of  inflammation  are  mechan- 
ical and  chemical  irritation  and  bacteria.  In  a  given  case  of  inflam- 
mation it  is  often  difficult  to  distinguish  sharply  between  these 
aetiological  factors,  particularly  between  the  action  of  chemical 
irritation  and  bacteria;  in  many  instances  there  is  certainly  no 
distinction.  In  this  respect,  what  is  true  elsewhere  in  the  body, 
is  true  also  as  regards  the  appendix. 

The  bacteriology  of  appendicitis  has  already  been  discussed. 
Of  the  production  of  appendicitis  by  chemical  irritants,  apart  from 
bacteria,  we  know  very  little.  That  mechanical  irritants,  such  as 
traumas,  act  as  exciting  causes  of  appendicitis  is  suggested  by  the 
development  of  appendicitis  following  injuries,  such  as  blows  in 
the  region  of  the  appendix,  sudden  straining  efforts,  etc.  These 
traumas  may  act  as  do  traumas  generally,  reduce  the  vitality  of 
the  appendix,  and  permit  of  the  more  ready  operation  of  the  excit- 
ing cause  of  appendicitis — bacteria.  The  relationship  of  trauma 
to  appendicitis,  however,  cannot  be  close  and  it  seems  doubtful 
whether  it  has  any  influence  whatever  except  under  very  unusual 
circumstances.  Byron  Robinson  considers  that  the  chief  exciting 
cause  of  appendicitis  is  the  action  of  the  right  psoas  muscle,  and 


Pathology  165 

Edebohls  believes  that  a  movable  right  kidney  is  of  prime  im- 
portance. He  states  that  chronic  appendicitis  is  present  in  from 
80  per  cent,  to  90  per  cent,  of  women  with  symptom-producing 
movable  right  kidney,  and  that  chronic  appendicitis  is  one  of  the 
chief,  if  not  the  chief  symptom  of  movable  kidney. 

It  is  well  remembered  that  early  in  the  development  of  our 
knowledge  concerning  appendicitis  the  origin  of  the  disease  was 
commonly  attributed  to  the  presence  in  the  appendix  of  various 
foreign  bodies,  such  as  cherry-stones,  grape-seeds,  seeds  of  various 
other  fruits,  pins,  needles,  hair,  bits  of  bone,  gall-stones,  and  the 
like.  Of  recent  years,  as  a  result  of  more  careful  investigation,  it 
has  become  evident  that  many  of  the  formations  previously  con- 
sidered seeds  of  various  fruits  were  in  reality  but  faecal  concretions 
or  appendicular  calculi,  the  misconception  as  to  their  real  nature 
being  due  to  the  resemblance  that  they  bore  in  size  and  shape  to  the 
different  objects  for  which  they  were  mistaken.  Undoubtedly, 
foreign  bodies  do  gain  access  to  the  appendix,  and  in  the  event  of 
that  organ  subsequently  becoming  the  seat  of  inflammation,  it  is  but 
natural  to  ascribe  an  aetiological  role  to  such  foreign  body. 

My  own  investigations  certainly  indicate  the  infrequency  of 
foreign  bodies  as  a  cause  of  appendicitis.  In  one  case  I  found  a 
pin  and  have  occasionally  encountered  the  seeds  of  various  fruits 
and  even  small  bird  shot.  These  findings  are,  however,  exceed- 
ingly rare  in  comparison  with  the  prevalence  of  appendicitis  and 
may  be  considered  practically  as  fortuitous.  It  is  interesting  to 
recall  that  various  enterozoa  have  been  found  in  the  appendix. 
Thus,  Oxyuris  vermicularis,  Trichocephalus  dispar,  and  Ascaris 
lumbricoides  have  been  encountered.  In  addition,  Scholler  has 
reported  a  case  of  echinococcus  of  the  appendix  in  association 
with  echinococcus  of  the  liver,  and  Birch-Hirshfeld  an  instance  of 
echinococcus  of  the  appendix  alone. 

While,  in  the  light  of  recent  experimental  and  other  scientific 
research,  the  view^s  formerly  maintained  with  regard  to  the  role  of 
various  foreign  bodies  in  the  production  of  appendicitis  has  largely 
been  abandoned,  the  relation  of  what  we  now  know  to  be  appen- 
dicular calculi  to  the  development  of  appendicitis  still  demands 
careful  consideration.  That  calculi  may  be  borne  in  the  intestinal 
tract  and  in  the  appendix  without  inducing  any  important  patho- 


1 66  Appendicitis 

logical  process  is  well  established  as  a  result  of  the  investigations 
of  a  considerable  number  of  observers,  and  is  being  constantly 
confirmed  by  all  who  have  occasion  to  see  much  necropsy  work. 
On  the  other  hand,  that  calculi  are  associated  with  a  considerable 
number  of  cases  of  appendicitis  is  equally  well  established.  The 
statistics  of  various  observers  with  regard  to  the  frequency  of  appen- 
dicular calculi  in  appendicitis  have  already  been  cited.  Of  460  of 
the  cases  examined  by  myself  they  were  found  in  74  (16  per  cent.) — 
35  of  a  total  of  208  acute  cases,  and  39  of  a  total  of  252  chronic 
cases.  The  35  instances  in  which  they  were  found  in  cases  of  acute 
appendicitis  were  distributed  among  the  different  varieties  of  this 
affection  as  follows: 

Of      7  cases  of  acute  catarrhal  appendicitis None. 

Of    32  cases  of  acute  interstitial  appendicitis 2(6.2  per  cent.). 

Of    56  cases  of  acute  ulcerative  appendicitis,  without 

perforation 9  (16  .0  per  cent.)- 

Of    64  cases  of  acute  ulcerative  appendicitis  with 

perforation 19  (29  .8  per  cent.). 

Of    49  cases  of  acute  gangrenous  appendicitis 5  (10.2  per  cent.). 

Of  208  cases  of  acute  appendicitis,  calculi  in 35  (16.6  per  cent.) . 

From  these  statistics  it  is  evident  that  calculi  are  present  in  a 
considerable  number  of  cases  of  acute  appendicitis,  and  it  is  further 
plain  that  the  more  severe  the  inflammatory  lesions,  the  greater  the 
proportion  of  cases  in  which  they  are  found.  Thus,  they  are  more 
common  in  cases  of  ulcerative  appendicitis,  especially  with  perfora- 
tion, and  in  gangrenous  appendicitis,  than  in  any  of  the  other  acute 
varieties.  There  can,  however,  be  no  question  that  they  are  even 
more  often  associated  with  some  varieties  of  acute  appendicitis 
than  the  foregoing  figures  indicate.  It  not  infrequently  happens  in 
cases  of  ulcerative  appendicitis  with  perforation,  and  in  gangrenous 
appendicitis,  that  at  the  time  of  operation  or  necropsy  the  calculus 
has  already  escaped  from  the  lumen  of  the  appendix  and  is  not 
detected  during  the  operative  manipulations,  or,  being  detected, 
is  not  preserved. 

The  relation  of  these  calculi  to  appendicitis,  however,  is  not 
the  simple  one  of  cause  and  effect,  as  was  originally  assumed.  A 
consideration  of  the  anatomy  of  the  caecum  and  appendix  is  sufficien 


Pathology  167 

to  indicate  the  impossibility  of  formed  calcuH,  even  of  small  size, 
gaining  access  to  the  appendix — at  all  events,  after  the  first  year  of 
life.  (During  the  last-named  period  the  appendicular  orifice  is 
often  quite  patulous).  This  view  has  been  confirmed,  if  such  con- 
firmation were  necessary,  by  some  experimental  investigations. 
Calculi,  therefore,  are  formed  within  the  appendix. 

The  condition  of  the  cavities  of  normal  appendices  removed  at 
necropsy  varies  in  different  instances.  It  has  been  found  entirely 
empty;  but  in  most  cases  it  is  partly  or  completely  filled  with  fluid 
or  semifluid  faecal  matter.  It  is  natural  to  infer  that  such  fsecal 
matter  frequently  gains  access  to,  and  is  as  frequently  expelled 
from,  the  lumen  of  the  appendix  by  the  muscular  contractions  of 
the  organ,  which  are  aided  by  the  shape,  position,  length,  calibre  of 
the  lumen  of  the  organ,  etc.  If  such  faecal  matter  remain  long  in 
the  appendix,  it  becomes  inspissated,  in  consequence  of  the  rapid 
absorption,  by  the  numerous  lymphatics,  of  its  watery  constituents. 
The  longer  it  remains,  the  more  inspissated  it  becomes.  It  is  prob- 
ably the  efforts  of  the  appendix  to  expel  such  inspissated  faecal 
matter  and  calculi  that  give  rise  to  attacks  of  appendicular  colic,  the 
occurrence  of  which  cannot  well  be  doubted.  Nor  can  it  be  doubted 
that  such  colicky  pain  occurs  in  the  absence  of  calculi  and  faecal 
matter  from  the  appendix.  The  irregular  peristalsis  of  an  inflamed 
and  ulcerated  appendix  is  of  itself  sufficient  to  give  rise  to  acute  pain, 
which  increases  in  wave-like  exacerbations — the  manifestations 
being  similar  to  the  tenesmus  of  a  posterior  urethritis  or  a  proctitis. 
If  the  egress  of  faecal  matter  from  the  appendix  be  hindered  by 
inappropriate  position  or  fixation  of  the  organ,  internal  constrictions, 
external  bands  of  cicatricial  connective  tissue,  swelling  of  the 
mucous  membrane  or  of  Gerlach's  valve,  flexures,  angulations, 
weakness  of  the  muscular  coats,  impassiveness  of  the  organ,  or 
other  causes,  the  contents  become  correspondingly  more  inspissated. 
From  what  was  originally  a  mass  of  faecal  matter  of  greater  or  less 
size,  a  small,  hardened,  faecal  particle  results.  Around  this  as  a 
nucleus  inspissated  mucus,  desquamated  epithelial  cells,  pus- 
corpuscles,  debris,  etc.,  are  deposited,  in  successive  concentric 
layers.  These,  collectively,  result  in  the  formation  of  a  so-called 
fascal  concretion.  Inasmuch,  however,  as  only  the  central  nucleus 
of  this  concretion  consists  of  faecal  matter,  the  remainder  of  it  being 


1 68  Appendicitis 

made  up  of  the  products  of  inflammation,  etc.,  the  preferable  desig- 
nation is  appendicular  calculus. 

Chemical  investigation  of  these  calculi  shows  that  they  are 
composed  of  phosphate,  carbonate,  and  sulphate  of  calcium;  phos- 
phate of  magnesium;  at  times  cholesterin,  fat,  debris,  etc.  Interest- 
ing investigations  have  recently  been  made  by  Ribbert,  who,  in 
addition  to  confirming  the  older  \dew,  according  to  which  the  centre 
of  the  calculus  alone  is  made  up  of  faecal  matter,  showed,  by  means 
of  Weigert's  fibrin  stain,  that  the  mucus  of  the  outer  layers  of  the 
calculus  is  in  continuous  association  with  that  filling  up  the  mucous 
glands  lining  the  appendix.  It  is  quite  likely  that  faecal  matter  of 
itself,  if  retained  in  the  appendix  for  some  time,  is  capable  of  setting 
up  some  catarrhal  inflammation,  and  this,  probably,  as  a  conse- 
quence not  only  of  attrition  of  the  lining  membrane,  but  also  of 
increase  in  the  \irulence  of  the  retained  bacteria.  This  is  indicated 
by  the  many  instances  of  catarrh  of  the  appendix  found  at  necropsy 
in  the  absence  of  calculi.  This  catarrh  of  the  appendix  is  one  of 
the  most  fertile  sources  of  appendicular  calculi.  Not  only  do  the 
swelling  and  oedema  thus  produced  retard  the  exit  of  faecal  matter 
from  the  appendix  and  favor  its  inspissation  by  affording  oppor- 
tunity for  the  absorption  of  its  watery  constituents,  but  the  products 
of  the  catarrhal  inflammation  themselves  furnish  the  necessary 
ingredients — the  salts — to  be  deposited  in  layers  about  the  nucleus 
of  faecal  matter. 

Calculi  in  the  appendix  vary  in  number,  size,  shape,  and  color. 
They  may  be  single  or  multiple.  Usually,  there  is  but  one;  there 
are  often  two;  there  are  rarely  more  than  four.  According  to 
Volz,  they  vary  in  size  from  that  of  a  lentil  to  that  of  a  hazelnut. 
The  largest  calculi  that  I  have  encountered  were  from  a  case  of 
gangrenous  appendicitis  of  five  days'  duration,  the  patient  being 
reported  never  to  have  had  any  previous  attacks.  The  appendix 
removed  at  operation  contained  three  concretions.  The  largest 
was  2  cm.  in  length  and  1.2  cm.  in  diameter;  the  second,  2  cm.  in 
length  and  i  cm.  in  diameter;  and  the  smallest,  0.8  cm.  in  length 
and  0.4  cm.  in  diameter.  The  calculi  are  usually  elongated;  though 
some  are  relatively  much  thicker  than  other?.  They  are  commonly 
rounded  at  the  extremities.  Sometimes,  however,  they  are  dis- 
tinctly conoid  or  pointed,  as  were  the  two  largest  of  those  the  dimen- 


Pathology  169 

sions  of  which  have  just  been  cited.  Externally,  they  may  be 
smooth  or  rough.  In  color  they  are  grayish-white,  yellowish,  or 
brownish.  On  section,  they  present  a  distinctly  lamellated  con- 
centric structure,  and  are  harder  toward  the  centre  than  toward 
the  periphery. 

Sonnenburg,  writing  of  the  formation  of  such  calculi,  or,  rather, 
of  the  deposition  of  successive  layers  about  the  central  nucleus, 
asserts  his  belief  that  there  must  have  existed  a  dilatation  of  the 
appendix  at  the  site  where  such  calculi  have  formed.  He  believes 
that  the  deposition  of  successive  layers  is  impossible  in  case  the  wall 
of  the  appendix  surrounds  the  calculus  firmly  as  an  unyielding  band, 
and  that,  therefore,  a  certain  space  is  essential  in  order  that  mucus 
and  other  ingredients  may  gain  access  to  the  faecal  particle.  The 
roundish  form  of  the  calculi  is  also  thought  to  indicate  that  they 
have  been  subject  to  more  or  less  movement.  Were  there  not  a 
certain  free  space,  calculi  of  excessive  size  would  certainly  lead  to 
rupture  before  they  do.  Be  these  suppositions  as  they  may,  calculi 
certainly  form  part  of  a  vicious  circle  in  appendicitis.  Originally, 
they  are  hardly  the  cause  of  appendicitis;  rather  are  they  the  result 
of  inflammation  of  the  appendix.  But  ha\dng  resulted  from  an 
attack  of  appendicitis,  they  are  an  important  factor  in  continuing 
the  inflammation,  in  furnishing  the  necessary  irritant  to  incite  re- 
newed attacks  of  acute  exacerbation,  and  in  contributing  to  some  of 
the  most  disastrous  consequences  of  appendicitis — perforation  and 
consequent  purulent  peritonitis.  Granting  that  the  attainment  of 
a  certain  size  presupposes  more  or  less  of  a  free  lumen,  when  that 
size  has  been  reached,  the  constant  pressure  and  attrition  of  the 
calculus  naturally  results  in  further  inflammation,  erosion,  ulcera- 
tion, and  perforation.  As  already  intimated,  catarrhal  inflamma- 
tion, with  hypersecretion  of  mucus,  desquamation  of  epithelial  cells, 
and  purulent  exudate,  afTord  ample  opportunity  for  the  increase  in 
size  of  the  calculi;  the  inflammation  renders  the  wall  of  the  appendix 
less  resistant  to  the  operations  of  bacteria  and  to  the  mechanical 
effects  of  the  calculi;  and  the  implication  of  the  muscular  coats 
lessens  or  prevents  peristalsis  and  diminishes  the  likelihood  of  the 
extrusion  of  the  calculus. 

Considering,  now,  the  relative  roles  played  by  bacteria  and 
appendicular  calculi  in  the  causation  of  appendicitis,  it  seems  to 


1 70  Appendicitis 

me  that  it  may  be  unhesitatingly  asserted  that  appendicitis  is, 
without  exception,  an  infectious  process;  that  the  inflammations  of 
the  appendix  are  the  results  of  the  activities  of  bacteria;  and  that 
the  role  of  calculi  is  quite  subsidiary  to  that  of  bacteria.  Such  being 
the  case,  the  queries  naturally  suggest  themselves:  Why  is  it  that 
bacteria  normally  present  in  the  intestinal  tract  are  provocative  of 
such  serious  pathological  lesions  in  the  appendix?  and  why  is  it 
that  calculi  innocuous,  or  almost  so,  in  the  intestine  are  associated 
with  inflammatory  affections  of  the  appendix?  The  reasons  for 
these  are  to  be  found  in  the  anatomical  and  physiological  peculi- 
arities of  the  appendix,  of  which  mention  has  already  been  made. 
These,  on  the  one  hand,  decrease  the  capability  of  the  organ  to 
resist  the  influences  of  various  morbific  agencies,  and,  on  the  other, 
afford  opportunities  for  the  rapid  increase  in  \drulence  of  bacteria 
contained  within  the  appendix.  Because  of  the  previously  detailed 
anatomical  and  physiological  peculiarities,  morbific  agencies  that 
are  readily  overcome  by  the  normal  physiological  activities  of  the 
intestinal  tract  are  capable,  when  present  in  the  appendix,  of  induc- 
ing the  most  deleterious  consequences.  And,  in  addition,  when 
these  morbific  agencies — principally  bacteria — become  heightened 
in  virulence,  they  effect  their  disastrous  results  much  more  readily. 
It  must  also  be  borne  in  mind  that  disease  is  due  not  alone  to  the 
virulence  of  the  determining  cause — be  it  bacteria,  trauma,  or  other 
cause — but  is  dependent  to  a  considerable  degree  upon  the  pre- 
disposition of  the  individual,  upon  the  vitality,  the  power  of  resist- 
ance, not  only  of  the  part  affected,  but  also  of  the  general  economy. 

To  Recapitulate :  The  factors  that  operate  to  render  the 
appendix  less  resistant  than  other  portions  of  the  intestinal  tract 
to  the  onslaughts  of  bacteria  and  other  determining  causes  of  appen- 
dicitis are  several.  Of  prime  importance  is  the  precarious  blood 
supply  and  the  consequent  anaemia  of  many  of  the  appendices. 
The  blood  supply  is  defective  not  so  much  because  of  the  manifest 
alterations  frequently  demonstrable  in  the  w^alls  of  the  blood-vessels 
of  presumably  normal  appendices,  but  also  because  of  the  liability 
of  the  occurrence  of  partial  or  complete  obstruction  of  the  blood 
channels  as  a  result  of  angulations,  torsions,  external  constricting 
bands  of  adhesions,  etc.,  and  of  infective  endo vasculitis  secondary 
to  primary  inflammation  of  the  appendix.     Disturbances  of  circu- 


Pathology  171 

lation,  and  hence  of  nutrition,  are  also  produced  by  active,  and 
sometimes  ineffectual,  peristalsis  of  the  appendix  induced  by  an 
effort  to  rid  itself  of  foreign  bodies,  calculi,  or  even  inspissated 
faecal  matter.  The  action  of  such  circulatory  and  nutritional  dis- 
turbances is  further  evident  in  the  intense  congestion  often  noted 
distal  to  an  appendicular  calculus  about  which  the  wall  of  the 
appendix  may  be  firmly  contracted,  and  by  the  fact  that,  under 
these  circumstances,  when  perforation  occurs,  the  part  affected  is 
not  directly  over  the  site  of  the  calculus,  but  rather  distal  to  this — 
the  region  of  the  previous  intense  congestion.  Of  importance  in  a 
limited  number  of  cases  are  also,  doubtless,  alterations  in  the  nerves 
supplying  the  appendix;  but,  as  already  stated,  it  is  believed  that 
these  are  not  of  such  great  importance  as  has  been  suggested  by 
Fowler  and  Van  Cott.  Finally,  in  this  connection,  not  without 
significance  are  the  evidences  of  retrogression  of  the  appendix, 
indicating,  as  they  do,  defective  powers  of  resistance.  The  factors 
that  in  the  appendix  g'ive  rise  to  increase  in  the  virulence  of  the  bac- 
teria normally  present  in  the  intestine  are  primarily  such  as  interfere 
with  thorough  drainage  of  the  organ.  Defective  drainage  may 
supervene  when,  for  any  reason,  the  appendix  is  so  situated  that  it 
cannot  be  readily  emptied;  when  its  lumen  is  constricted,  either 
externally  by  bands  of  cicatricial  connective  tissue  (peritoneal 
adhesions),  tumor  formations,  etc.,  or  by  cicatrices  of  its  wall,  or 
by  obstructions  within  its  lumen  (as,  for  instance,  by  calculi  or 
foreign  bodies) ;  or  when  the  muscular  coat  of  the  organ  is  no  longer 
capable  of  active  peristalsis  as  is  likely  to  be  the  case  when  the  ap- 
pendix is  itself  diseased  or  bound  down  by  adhesions.  Congestive 
disturbances  of  the  appendix  or  of  the  caecum  may  cause  such 
swelling  of  the  mucous  membrane  as  to  lead  to  approximation  of  the 
opposed  surfaces  in  the  appendix,  or  to  occlusion  of  the  outlet  of  the 
organ,  and  thus  effectually  prevent  drainage.  Of  considerable 
significance  with  reference  to  this  question  of  drainage  are  certain 
of  the  anatomical  and  physiological  peculiarities  of  the  organ  pre- 
viously described.  Of  these,  may  be  mentioned  the  size  and  shape 
of  the  meso-appendix,  the  excessive  length  as  compared  with  the 
calibre  of  the  lumen  of  the  appendix,  and  Gerlach's  valve.  As 
further  conducive  to  imperfect  drainage  are  the  already  mentioned 
torsions,  angulations,  peritoneal  adhesions,  cicatrices  of  the  wall  of 


172  Appendicitis 

the  appendix,  etc.,  which  interfere  not  alone  with  the  blood  supply, 
but  also  with  thorough  drainage.  Appendicular  calculi  are  capable 
of  at  least  a  two-fold  action,  and  that  within  a  vicious  circle. 
Originally  resulting  from,  rather  than  causing  an  attack  of,  appen- 
dicitis, they  may  not  only  occlude  the  lumen  of  the  organ  and  pre- 
vent drainage,  but  they  may  also  induce  passive  congestion  in  that 
portion  of  the  appendix  distal  to  their  situation,  and  by  attrition — 
the  result  of  constant  or  intermittent  peristalsis — cause  erosions  of 
the  mucous  membrane,  and  thus  reduce  the  power  of  the  organ  to 
resist  the  attacks  of  bacteria  and  their  toxins.  When  small,  these 
calculi  are  often  doubtless  innocuous;  but  when  they  have  attained 
a  considerable  size,  and  are  no  longer  capable  of  being  extruded, 
they  may  engender  the  most  disastrous  consequences.  The  erosion 
and  necrosis  of  the  mucous  membrane,  resulting  from  constant  at- 
trition, progress,  affecting  all  the  coats,  until  perforation  may  be 
produced.  As  the  erosion  or  ulceration  increases  there  is  afforded 
a  favorable  focus  for  the  ready  invasion  of  bacteria  and  the  free 
absorption  of  their  toxins.  Thus,  while  calculi  are  of  subsidiary 
importance  in  exciting  the  original  attack  of  appendicitis,  it  is 
believed  that  in  many  cases  they  are  of  very  great  importance  in 
determining  perforation  of  the  appendix  and  the  situation  of  the 
perforation.  These  are  evident  from  the  preponderating  number 
of  cases  in  which  calculi  are  found  in  ulcerative  appendicitis  with 
perforation,  and  in  the  direct  association  of  the  calculus  with  the  site 
of  the  perforation.  In  addition,  appendicular  calculi  are  of  con- 
siderable significance  in  the  production  of  chronic  recurring  appen- 
dicitis, in  provoking  the  acute  exacerbations  in  a  chronically  inflamed 
appendix. 

The  preponderating  importance  of  defective  drainage  in  the 
pathogenesis  of  appendicitis  is  sufficiently  evident  from  an  ex- 
amination of  a  large  number  of  diseased  appendices,  but  it  finds 
additional  confirmation  from  the  clinical  and  pathological  ob- 
servation of  analogous  intestinal  conditions  and  from  some  ex- 
perimental investigation.  Increase  in  the  virulence  of  bacteria, 
particularly  of  the  common  colon  bacillus,  has  been  found  not  only 
in  the  appendix  when  its  lumen  has  been  obstructed,  but  also,  as 
already  mentioned,  in  cases  of  intestinal  obstruction  and  strangu- 
lation, in  various  congestive  and  diarrhoeic  conditions,  and  even  in 


Pathology  173 

some  cases  of  marked  and  long-continued  constipation.  The  ex- 
perimental investigations  of  Roux,  Roger  and  Josue,  Dieulafoy, 
Frazier,  and  others  are  especially  noteworthy  as  indicating  the  in- 
crease in  the  virulence  of  the  common  colon  bacillus  in  the  appendix 
when  its  lumen  is  occluded.  A  hollow  glandular  organ  remains 
intact  only  as  long  as  the  production  and  evacuation  of  its  secretion 
goes  on  normally.  As  soon  as  there  occurs  a  disturbance,  either 
overproduction  or  diminished  evacuation,  disease  results.  If  the 
excretory  duct  of  the  gall-bladder  be  occluded,  there  ensues,  under 
varying  circumstances,  either  a  hydrops,  an  empyema,  or  a  cholecys- 
titis or  a  cholangitis.  The  same  is  also  true  of  the  mammary  gland, 
of  the  sebaceous  glands  of  the  skin,  and  of  the  appendix."  When 
the  lumen  of  the  latter  becomes  obstructed,  there  occur  retention, 
stagnation,  and  decomposition  of  its  contents.  This  stagnation 
contributes  also  to  the  vicious  circle,  in  that  it  not  only  exerts  a 
deleterious  influence  on  the  wall  of  the  appendix  by  reason  of  the 
mechanical  pressure  to  which  it  gives  rise,  but  it  also  serves  as  a  most 
suitable  culture  medium  for  the  growth  of  bacteria.  When  to  the 
products  of  decomposition  there  are  added  the  toxins  produced  by 
the  retained  bacteria  increasing  in  virulence,  the  cause  of  appen- 
dicitis is  self-evident. 

As  additional  factors  of  importance  are  the  relatively  large  extent 
of  mucous  membrane  presented  by  the  appendix  and  the  large 
amount  of  lymphoid  tissue,  not  only  in  the  neighborhood  of  Gerlach's 
valve,  but  also  scattered  throughout  the  wall  of  the  appendix.  The 
latter  is  of  especial  significance  in  view  of  the  proneness  of  adenoid 
tissue  throughout  the  body  to  inflammation  whenever  subject  to 
even  slight  irritation  by  bacteria  and  their  toxins.  The  mucous 
membrane,  particularly  if  it  be  eroded  or  ulcerated,  presents  a 
very  large  surface  for  the  ready  invasion  of  bacteria  and  for  the 
absorption  of  their  toxins.  This  latter  is  of  especial  importance 
in  the  production  of  gangrene  of  the  appendix — the  result  often  of 
infective  thrombosis  or  embolism  following  erosion  or  ulceration 
of  the  wall  of  the  appendix. 

It  must  also  be  remembered  that  the  appendix  is  prone  to 
participate  in  severe  intestinal  lesions,  particularly  those  of  typhoid 
fever  and  dysentery;  and  while  the  latter  may  subside  without  the 
production  of  appendicitis,  there  frequently  persist  sequels,  in  the 


1 74  Appendicitis 

form  of  cicatrices,  etc.,  that  are  not  without  significance  in  the  cau- 
sation subsequently  of  inflammation  of  the  appendix.  Further, 
Klecki  and  other  investigators  have  shown  that  Bacterium  coli  com- 
mune differs  in  virulence  in  various  portions  of  the  intestinal  tract. 
It  is  most  virulent  in  the  ileum,  less  so  in  the  jejunum,  and  least 
virulent  in  the  duodenum  and  colon.  It  is  conceivable  that  the 
attacks  of  indigestion  accompanied  by  diarrhoea  that  in  many 
instances  precede  the  outbreak  of  appendicitis  may  result  in  the 
conveyance  to  the  appendix  of  virulent  bacteria,  and  that  these 
overcome  the  resistance  of  the  appendix  more  readily  than  do  the 
less  virulent  bacteria  normally  present  in  the  appendiculo-cascal 
region.  On  the  other  hand,  increase  in  the  virulence  of  Bacterium 
coli  commune  has  been  found  in  the  cases  of  marked  constipation 
which,  as  is  well  known,  sometimes  precede  the  development  of 
appendicitis. 

From  the  foregoing,  therefore,  it  is  evident  that  no  one  factor 
alone  can  be  held  answerable  for  the  production  of  all  cases  of 
appendicitis.  Although  the  affection  is  without  exception  the  con- 
sequence of  micro-organismal  infection,  it  is  of  rather  complex 
pathogenesis,  and  no  one  morbific  agent  is  provocative  of  all  attacks. 
It  is  because  of  the  anatomical  and  physiological  peculiarities  of 
the  appendix  that  factors  innocuous  in  the  intestine,  or  morbific 
agents  capable  of  being  successfully  combated  by  the  physiological 
activities  of  the  intestine,  become,  in  the  appendix,  of  heightened 
virulence  and,  meeting  lessened  resistance,  engender  the  most  dis- 
astrous consequences.  Finally,  it  is  interesting  to  mention  that 
Goluboif  regards  appendicitis  as  an  infectious  disease  sui  generis, 
as  are  follicular  tonsillitis,  dysentery,  etc.,  and  that  he  expresses  the 
opinion  that,  in  addition  to  the  occurrence  of  sporadic  cases,  the 
affection  may  develop  epidemically — that  it  is  then  an  epidemic 
infectious  disease.  But  this  view  can  hardly  be  maintained  with 
reason. 


SYMPTOMATOLOGY. 

In  considering  the  symptomatology  of  acute  appendicitis  it  must 
be  borne  in  mind  that  it  is  not  always  possible  to  determine  the 
pathological  alterations  in  the  appendix  from  the  clinical  manifes- 
tations of  the  disease.  It  is  futile  to  ascribe  to  any  symptom  or 
symptom-complex  pathognomonic  significance  with  regard  either 
to  the  progress  or  to  the  stage  of  the  affection.  It  is  true  that  there  is 
a  symptom-complex  which,  when  present,  warrants  us  in  assuming 
the  existence  of  mild  appendicitis,  or  in  assuming  that  the  inflam- 
mation is  confined  to  the  appendix;  that  there  is  another  symptom- 
complex  that  suggests  appendicitis  with  circumscribed  peri-appen- 
dicular  suppuration;  and  that  there  is  still  another  syptom- 
complex  indicative  of  appendicitis  with  diffuse  peritonitis.  Such, 
however,  are  the  manifold  differences  in  the  clinical  manifestations 
of  similar  anatomical  lesions  of  the  appendix  that  the  establish- 
ment of  symptom-complexes  that  shall  indicate  definite  pathological 
lesions  of  the  appendix  is  impossible.  There  can  be  no  question 
that  reliance  upon  such  symptom-complexes  as  have  been  formu- 
lated frequently  leads  to  egregious  diagnostic  blunders.  While 
it  is  true  that,  in  general,  the  clinical  manifestations  become  more 
marked  with  increase  in  the  severity  of  the  appendicular  and  peri- 
toneal lesions — that  is,  when  perforation,  pus  formation,  or  gangrene 
supervene — it  is  also  a  fact  that  remission  of  all  symptoms,  except 
local  tenderness,  may  occur,  and  yet  the  disease  may  be  progressing 
to  a  fatal  termination.  It  is  likewise  a  fact  that  the  symptoms 
suggestive  of  perforation  of  the  appendix  and  peri-appendicular 
suppuration  in  one  patient  may  arise  in  another  patient  in  conse- 
quence of  the  development  of  peri-appendicular  suppuration 
without  perforation  of  the  organ.  It  thus  seems  rational  not  to 
attempt  to  separate  clinically  cases  of  appendicitis  in  groups — such 
as  mild  or  non-perforative,  gangrenous,  etc. — ^but  to  describe  acute 
appendicitis  as  a  clinical  entity  whose  manifestations  seem  more 
dependent  upon  the  virulence  of  the  infection  and  the  resistance  of 
the  individual  than  upon  the  character  of  the  lesions  of  the  appen- 

175 


176  Appendicitis 

dix  and  the  surrounding  peritoneum.  Similar  reasoning  obtains 
with  regard  to  chronic  appendicitis,  although  in  the  latter  the  ques- 
tions requiring  solution  are  less  complicated.  In  the  vast  majority 
of  cases  of  chronic  appendicitis  the  entire  organ  is  affected,  and  such 
can  be  assumed  with  justice  in  the  presence  of  the  appropriate 
clinical  symptoms.  The  supposition  that  merely  catarrhal  altera- 
tions exist  may  seem  warranted  in  some  cases,  but  examination  of 
the  excised  appendix  will  usually  reveal  pathological  lesions  of  all 
the  coats.  It  need  scarcely  be  mentioned  that  obliterative  appen- 
dicitis cannot  be  recognized  clinically. 

The  symptomatology  of  two  forms  of  appendicitis — the  acute  and 
the  chronic — ^will  be  described.  The  acute  form  embraces  those 
varieties  of  inflammation  of  the  appendix  usually  described  clinically 
as  simple  catarrhal,  ulcerative,  perforative,  fulminating  or  gangren- 
ous and  which,  upon  examination  of  the  excised  appendix,  reveal 
acute  catarrhal  or  interstitial  inflammatory  alterations,  ulceration 
with  or  without  perforation,  or  partial  or  complete  gangrene. 
These  terms  represent  in  great  part  only  differences  in  the  degree 
and  extent  of  the  local  inflammatory  phenomena — differences  be- 
tween which  it  is  impossible  in  all  instances  clinically  to  draw  a 
distinction.  The  chronic  form  of  appendicitis  includes  those  varie- 
ties described  clinically  as  subacute,  chronic,  relapsing,  and  recur- 
rent, and  which,  upon  examination  of  the  extirpated  appendix, 
reveal  chronic  catarrhal  and  interstitial  inflammatory  alterations, 
with  or  without  ulceration,  progressing  in  some  instances  to  oblitera- 
tion of  the  lumen  of  the  organ — obliterative  appendicitis. 

ACUTE  APPENDICITIS. 

There  are  three  symptoms  of  acute  appendicitis  so  constant, 
and  when  associated,  so  characteristic  of  the  affection  that  I  have 
designated  them  as  the  "three  cardinal  symptoms."  These  are 
pain,  tenderness  and  rigidity  of  the  right  lower  quadrant  of  the 
abdominal  wall. 

Pain  is  the  initial  symptom  in  all  cases.  It  usually  develops 
suddenly  in  one  previously  well,  continues  a  variable  length  of  time, 
recurs  at  irregular  intervals,  and  is  distinctly  cramp-like  or  colicky 
in  character.     It  has  frequently  been  observed  that  the  ingestion  of 


Symptomatology  177 

food,  especially  when  indigestible  or  improperly  cooked,  has  been 
followed  shortly  by  the  onset  of  the  attack.  More  often  however 
there  is  no  apparent  relation  to  the  taking  of  food. 

The  paroxysmal  character  of  the  initial  pain  cannot  be  insisted 
upon  too  strongly.  It  is  sometimes  spoken  of  as  appendicular 
colic,  but  the  term  seems  objectionable  because  in  its  general  accep- 
tation it  relegates  the  role  of  inflammation  to  a  position  subordinate 
to  the  mechanical  factors  of  spasm,  tension  and  distention.  Doubt- 
less there  are  cases  of  non-inflammatory  colic  due  to  the  efforts  of 
the  appendix  to  rid  itself  of  retained  mucus,  faecal  material,  concre- 
tions or  foreign  bodies.  Such  simple  colicky  attacks  are,  however, 
negligible  in  number  when  compared  to  the  usual  case  in  which 
the  painful  paroxysms  are  due  to  the  inflamed  state  of  the  organ, 
being  elicited  by  any  movement,  whether  active,  such  as  intrinsic 
peristalsis,  or  passive.  In  most  instances  both  inflammation  and 
mechanical  factors  are  instrumental  in  producing  the  pain  and  each 
if  originally  present  alone,  predisposes  strongly  to  the  other.  It  is 
quite  impossible  to  distinguish  clinically  between  the  two  types  of 
pain  since  they  differ  in  no  way.  The  use  of  the  term  appendiceal 
colic  therefore  implies  a  knowledge  that  no  one  ever  possesses  from 
clinical  observation  alone  and  any  painful  appendix  is  to  be  regarded 
as  an  inflamed  appendix. 

In  general  it  may  be  said  that  the  intensity  of  the  pain  bears  a 
direct  relation  to  the  severity  of  the  inflammatory  process,  yet  such 
are  the  individual  variations  in  sensibility  to  pain  and  its  depend- 
ence upon  the  anatomical  relations  of  the  appendix  that  any  effort 
to  gauge  the  extent  of  the  lesion  minutely  by  a  consideration  of 
the  pain  alone  is  sure  to  meet  with  failure. 

The  pain  continues  of  a  colicky  character  for  a  greater  or  less 
period  of  time,  when  the  paroxysms  gradually  lessen  in  number 
and  severity.  It  does  however  persist,  being  continuous  and  of 
moderate  severity,  though  acute  exacerbations  may  from  time  to 
time  occur.  Thay  may  come  on  apparently  spontaneously,  but  are 
likely  to  be  excited  by  a  number  of  causes.  The  passage  of  flatus 
through  the  ileo-caecal  valve  is  the  chief  of  these,  but  palpation  or 
any  movement  of  the  psoas  muscle  by  motion  of  the  right  thigh  or 
disturbance  of  the  abdominal  muscles  by  coughing,  sneezing,  etc., 
act  in  the  same  manner.     I  have  found  the  pain  which  is  brought 


T  78  Appendicitis 

out  by  deep  breathing  or  coughing  of  considerable  assistance  in  the 
diagnosis.  Later  on  in  the  course  of  the  attack  the  pain  may- 
moderate  considerably  and  this  may  be  an  evidence  of  the  sub- 
sidence of  the  attack.  Frequently,  however,  it  is  but  an  indica- 
tion of  perforation  or  gangrene.  Particularly  is  the  sudden  cessation 
of  previously  severe  pain  a  bad  rather  than  a  good  omen  as  it 
often  indicates  the  presence  of  a  rapid  gangrene  of  the  appendix. 

In  some  exceptional  cases  the  pain  is  non-paroxysmal,  constant 
and  dull  from  the  very  onset  of  the  attack.  This  is  especially 
likely  to  be  the  case  in  recurring  attacks,  when  the  pain  is  often 
described  as  of  a  peculiar  boring  character.  It  may  indeed  come 
on  very  insidiously,  beginning  as  a  dull  ache  and  gradually  reaching 
a  maximum  and  then  subsiding.  Such  an  onset  of  an  acute  appen- 
dicitis is  particularly  liable  to  occur  in  older  subjects  and  especially 
the  aged,  and  is  most  dangerous  because  the  apparent  mildness 
of  the  onset  lulls  us  into  a  false  security. 

The  initial  pain  is  in  the  majority  of  cases  referred  to  the  umbil- 
ical region,  next  in  order  of  frequency,  to  the  epigastrium,  and 
least  commonly  to  the  right  iliac  fossa.  The  typical  pain  of  an 
attack  of  acute  appendicitis  is  that  which  develops  suddenly  in 
one  previously  well,  is  cramp-like  in  character,  referred  to  the 
umbilical  or  epigastric  regions  and  later  becomes  localized  in  the 
right  iliac  fossa.  The  pain  of  appendicitis  may,  however,  be 
referred  to  any  region  of  the  abdomen,  largely  depending  on  the 
position  of  the  appendix.  Lack  of  knowledge  of  this  fact  has  led  to 
many  errors  in  the  diagnosis  of  acute  abdominal  affections. 

Rarely,  we  meet  with  a  case  of  acute  appendicitis  of  a  mild 
nature  in  which  no  history  of  subjective  pain  is  obtainable  and  I 
have  observed  this  in  young  people  and  particularly  in  children. 
At  times  such  an  attack  is  unassociated  even  with  tenderness  and 
when  this  is  so,  a  diagnosis  except  upon  the  basis  of  a  previous 
history  is  impossible. 

The  secondary  pain  in  an  attack  of  acute  appendicitis  is  that 
which  results  from  the  peri-appendicular  involvement.  Its  loca- 
tion therefore  depends  almost  entirely  upon  that  of  the  appendix  and 
the  extent  of  the  involvement  beyond  it.  After  the  development  of  a 
circumscribed  peritonitis  the  pain  is  usually  referred  to  the  right 
iliac  fossa,  because  the  appendix  commonly  occupies  this  region  of 


Symptomatology  179 

the  body.  If  the  appendix  be  long  and  overhangs  the  brim  of  the 
true  pelvis  the  pain  may  be  referred  to  the  left  side  of  the  abdomen, 
or  pelvis,  to  the  region  of  the  ovary  in  the  female,  or  along  the  course 
of  the  spermatic  cord  toward  the  testicle  in  the  male.  If  the  appen- 
dix is  post-caecal  with  a  diseased  tip  and  points  upward  the  pain  may 
be  referred  to  the  loin  or  back  or  to  the  region  of  the  kidney  or  liver. 
When  the  appendix  rests  upon  the  psoas  muscle  and  is  in  relation  with 
the  anterior  crural  nerve,  the  pain  may  be  referred  to  the  thigh  along 
this  nerve,  and  even  to  the  knee.  In  other  cases  the  pain  may  be 
referred  along  the  inguinal  branch  of  the  ilio-inguinal  nerve  to  the 
inguinal  canal,  or  to  the  area  of  distribution  of  the  right  genito- 
crural  nerve,  the  testicle  or  vulva,  or  the  upper  anterior  and  inner 
part  of  the  thigh.  When  the  pain  is  referred  to  the  right  testicle 
there  may  occur  retraction  of  the  organ  such  as  in  renal  colic. 
If  the  tip  of  the  organ  occupy  the  left  iliac  fossa  or  the  entire  appendix 
is  situated  there  the  pain  will  also  be  referred  to  this  region.  Such  a 
left-sided  pain  is,  however,  not  unknown  in  cases  in  which  operation 
discloses  no  abnormality  in  the  position  of  the  organ  and  a  diagnosis 
under  these  circumstances  may  be  extremely  difficult.  I  have  in 
mind  a  case  of  appendicitis  with  pain  at  all  times  left  sided  which 
escaped  recognition  for  three  weeks.  A  pelvic  and  left-sided  pus 
collection  then  rendering  operative  interference  imperative,  the  true 
origin  of  the  disease  was  discovered,  the  appendix  not  being  abnor- 
mally situated. 

Tenderness  on  pressure  is  one  of  the  most  valuable  signs  of 
acute  appendicitis.  This  tenderness  is  both  superficial  and  deep 
and  may  be  elicited  directly  or  indirectly. 

The  deep  tenderness,  caused  by  the  intra-  or  peri-appendicular 
inflammation  itself  is  by  far  the  more  reliable  and  important  of  the 
two.  The  area  of  tenderness  at  the  beginning  of  an  acute  attack  is 
small  and  is  limited  to  the  site  and  position  of  the  appendix.  This  is 
usually  at  McBurney's  point,  which  is  located  between  an  inch  and 
a  half  and  two  inches  from  the  anterior  superior  spine  of  the  right 
ileum  on  a  line  drawn  from  the  anterior  superior  spine  to  the  umbil- 
icus and  marks  for  all  practical  purposes  the  position  of  the  base  of 
the  appendix.  Or  the  tenderness  may  be  most  marked  at  Clado's 
point,  where  the  interspinous  line  crosses  the  right  semilunar  line. 
It  is  natural  to  expect  that  the  tenderness  should  be  over  the  seat  of 


i8o  Appendicitis 

the  most  marked  disease  of  the  appendix.  As  a  consequence  the 
most  tender  point  varies  more  or  less  with  the  position  of  the  appen- 
dix, and  if  the  appendix  be  post-caecal  with  marked  rigidity  of  the 
abdominal  walls,  tenderness  may  be  difficult  to  elicit  anteriorly. 
When  the  appendix  projects  into  the  pelvis  tenderness  may  not  be 
detected  except  by  rectal  or  vaginal  examination;  but  in  women  the 
possibility  of  ovarian  inflammation  giving  a  similar  tenderness  must 
be  borne  in  mind. 

While,  as  has  been  stated,  the  point  of  greatest  tenderness  is 
usually  over  the  inflamed  appendix,  there  are  occasional  exceptions 
to  this  rule.  Thus,  in  a  young  adult  I  found  the  point  of  greatest 
tenderness  to  the  left  of  the  left  rectus  muscle,  a  little  above  the  ante- 
rior superior  spine  of  the  ileum.  By  rectal  examination  a  small  and 
very  sensitive  mass  was  detected  in  the  recto-vesical  fossa  and  opera- 
tion showed  that  the  appendix  occupied  the  latter  position. 

After  the  extension  of  the  inflammation  beyond  the  appendix 
there  is  a  corresponding  extension  in  the  area  of  deep  tenderness. 
This  as  a  rule  corresponds  to  the  extent  of  the  spread  of  the  inflam- 
matory process.  The  tenderness  is  greater  over  a  forming  abscess 
or  over  the  area  of  a  diffusing  peritonitis  than  over  an  abscess  already 
formed,  though  even  in  the  latter  it  may  remain  exquisite  until  relief 
is  obtained.  I  have,  however,  observed  many  cases  of  appendiceal 
abscess  in  which  the  inflammatory  mass  was  not  markedly  sensitive 
to  pressure. 

General,  diffuse  or  diffusing  peritonitis  is  characterized  by  ex- 
treme general  abdominal  tenderness. 

Deep  tenderness  may  at  times  be  elicited  indirectly  by  the  method 
of  Rovsing.  He  has  shown  that  pressure  over  the  descending  colon 
at  a  point  corresponding  to  McBurney's  point  on  the  right  side  will 
give  pain  in  the  region  of  the  diseased  appendix.  Especially  is  this 
noted  when  the  palpating  hand  is  carried  upward  along  the  descend- 
ing colon.  This  referred  tenderness  is  caused  by  forcing  the  gas 
contained  in  the  colon  around  toward  the  ileo-caecal  region  and  is  in 
every  way  similar  to  that  obtained  by  direct  pressure.  I  have  not 
found  it  a  symptom  of  value. 

The  gradual  amelioration  of  tenderness  over  a  diseased  appendix 
in  most  instances  signifies  a  retrogression  of  the  disease  process. 
It  may  remain,  however,  as  vague  tenderness  in  the  right  iliac  fossa 


Symptomatology  i8i 

long  after  all  symptoms  have  disappeared,  and  indeed  may  never  be 
absent  entirely  between  acute  attacks.  The  sudden  subsidence  of 
tenderness  has  an  exactly  opposite  significance.  It  is  usually  an 
evidence  of  gangrene  of  the  appendix.  This  sudden,  and  at  times 
entire  cessation  in  tenderness,  particularly  in  a  case  with  a  sudden 
and  abrupt  onset  and  especially  when  accompanied  by  a  complete 
remission  of  pain  is  always  a  grave  sign.  This  is  perhaps  the  most 
deceptive  stage  of  an  acute  appendicitis,  for  whereas  the  patient's 
feeling  of  well-being  and  relief  from  distress  would  lead  us  to  believe 
that  he  is  better,  in  reality  he  is  but  entering  the  most  dangerous 
stage  of  his  illness. 

Superficial  .tenderness,  also  described  as  cutaneous  hyper- 
aesthesia,  is  due  to  reflex  stimulation  of  sensory  nerves  connected 
with  the  same  region  of  the  spinal  cord  as  are  the  nerves  supplying 
the  appendix.  This  symptom  has  been  especially  studied  by  Head 
and  Sherren  and  a  late  article  by  Bennet  has  again  drawn  attention 
to  its  importance.  It  is  best  detected  by  very  gentle  stroking  or 
pinching  motions,  commencing  in  an  unaffected  part  of  the  abdomen, 
and  gradually  approaching  the  sensitive  area,  which  may  be  thus 
quite  accurately  defined.  It  occupies  an  area  variously  shaped  but 
always  is  at  least  approximately  centered  by  the  location  of  the  appen- 
dix. This  superficial  tenderness  is  quite  constant  and  its  sudden  or 
gradual  disappearance  has  the  same  significance  as  a  corresponding 
change  in  the  deep  tenderness.  Its  diagnostic  value  is  somewhat 
lessened  by  its  occurrence  in  other  abdominal  conditions.  Thus 
Rolleston  observed  it  in  a  case  where  operation  disclosed  a  normal 
appendix,  but  the  presence  of  an  inflamed  and  softening  gland  near 
the  csecum. 

Rigidity  of  the  abdominal  muscles,  next  to  pain  and  tenderness, 
is  the  most  reliable  sign  of  appendicitis.  In  the  more  severe  type 
of  cases  and  when  the  initial  general,  epigastric  or  umbilical  pain  is 
marked  there  will  be  rigidity  of  the  entire  abdomen,  but  this  rigidity 
appears  to  be  under  the  control  of  the  patient  to  a  great  extent.  As 
the  pain  becomes  localized  to  the  right  iliac  fossa  the  abdominal 
muscles  on  the  right  side  present  a  constant,  often  board-like, 
resistance  to  the  palpating  hand.  The  rigidity  varies  in  degree  in 
different  cases,  but  is  generally  well  marked,  and  is  most  intense 
over  the  site  of  the  inflamed  appendix.     In  some  instances  the  rigid- 


1 82  Appendicitis 

ity  is  so  pronounced  that  it  precludes  palpation  of  either  the  appendix 
or  a  possible  peri-appendicular  abscess,  and,  in  addition,  gives  to 
the  percussion  note  a  high  pitch.  When  the  pain  has  been  referred 
to  the  left  side,  if  suppuration  supervenes,  and  the  pus  collection 
occupies  the  pelvis,  marked  bilateral  rigidity  of  the  recti  muscles 
and  of  the  lower  portion  of  the  abdominal  wall  develops.  When 
peritonitis  becomes  diffuse,  rigidity  of  the  entire  abdominal  wall 
occurs. 

Although  the  three  cardinal  symptoms  are  the  most  important 
indications  of  the  presence  of  acute  appendicitis,  there  are  other 
clinical  manifestations  that  present  themselves  with  more  or  less 
regularity,  and  are  of  value  in  the  diagnosis.  We  may  divide  them 
into  two  general  classes. 

Reflex  symptoms,  of  which  he  most  important  are  disturbances 
of  the  gastro-intestinal  tract  and  the  bladder  function,  and  the 
symptoms  of  infection,  of  which  we  may  mention  fever,  disturbances 
of  the  cardiac  and  respiratory  rhythm,  change  in  the  number  and 
character  of  the  leukocytes,  icterus  and  interference  with  the  func 
tion  of  the  kidneys. 

Nausea  and  vomiting  are  observed  almost  constantly.  The 
latter  occurs  after  the  onset  of  the  initial  pain  and  may  occur  but 
once.  The  initial  vomiting  is  either  the  result  of  the  abdominal 
pain  or  is  a  reflex  occurrence.  But  as  Ochsner  points  out,  its 
continuation  is  due  to  the  interference  with  the  passage  of  gas  and 
faeces  through  the  congested  and  partially  obstructed  ileo-caecal 
valve  and  subsequent  interference  w^ith  the  digestion  of  food  and 
consequent  return  peristalsis  into  the  stomach.  The  vomiting 
usually  subsides  with  the  localization  of  the  pain  in  the  right  iliac 
fossa,  unless  it  is  continued  by  the  ingestion  of  food  or  drugs.  The 
vomited  matter  consists  first  of  the  gastric  contents,  then  of  bile  or 
bile-stained  fluid  (the  duodenal  contents)  and  finally,  if  septic 
peritonitis  supervenes,  of  stercoraceous  material.  Hiccough  is 
sometimes  observed,  especially  if  the  appendix  point  upward  and 
peritonitis  has  developed;  more  particularly,  however,  if  the  dia- 
phragmatic peritoneum  is  involved. 

Constipation  is  the  rule  in  the  majority  of  cases.  Diarrhoea 
is  sometimes  present  at  the  outset  and  is  usually  associated  with 
intense  pain  and  a  less  favorable  prognosis.     In  606  of  my  own  cases 


Symptomatology  183 

constipation  was  observed  in  411,  diarrhoea  in  78,  alternate  constipa- 
tion and  diarrhoea  in  11,  and  in  106  the  bowels  were  normal. 

Formerly  much  stress  was  laid  on  the  role  of  constipation  as  a 
causative  factor,  but,  as  I  have  already  mentioned,  this  is  unim- 
portant. As  a  symptom,  it  is  due  to  reflex  paralysis  of  the  bowel 
often  associated  with  an  intestinal  paresis  the  result  of  infection  or 
of  the  excessive  use  of  opium  or  morphine.  Under  any  of  these 
conditions  the  constipation  may  be  so  severe  as  to  simulate  intestinal 
obstruction.  It  may,  however,  not  develop  at  the  onset  of  the  attack, 
but  its  definite  occurrence  may  be  postponed  until  the  third,  fourth 
or  fifth  day,  after  which  it  may  be  most  marked. 

Bladder  symptoms  may  also  be  present,  due  to  disturbance  of 
the  sympathetic  nervous  system  or  to  propagated  inflammation  of 
the  bladder  itself.  They  may  be  manifested  in  frequency  of  urination 
with  pain,  burning  or  urgency,  or  in  a  more  or  less  marked  retention. 
The  latter  and  also  the  more  severe  and  long-continued  examples 
of  frequency  of  urination  are  more  often  due  either  to  the  proximity 
of  a  pelvic  appendix  to  the  bladder  serosa  or  the  direct  irritation 
thereof  by  pelvic  exudate  or  pus.  Two  years  ago  I  had  occasion  to 
observe  a  case  of  this  nature.  The  patient  had  had  an  attack  of 
appendicitis  a  week  previously,  but  thought  he  had  recovered.  He 
came  under  my  care  at  the  German  Hospital  for  retention  of  urine 
and  examination  disclosed  its  cause  in  a  purulent  pelvic  peritonitis 
of  appendiceal  origin. 

The  temperature  varies  greatly  in  different  cases  of  the  same 
nature  and  in  general  is  a  most  unreliable  factor  in  both  diagnosis 
and  prognosis.  "A  very  high  temperature  usually  means  a  grave 
condition,  but  a  low  temperature  does  not  ensure  the  slightest  degree 
of  safety"  (Ochsner).  In  what  may  be  termed  a  typical  attack  of 
appendicitis  there  is  usually  moderate  fever.  That  is,  at  the  com- 
mencement of  the  attack  there  is  generally  fever  that  amounts  to 
101°  to  103°  F.  or  more.  The  temperature  usually  rises  rapidly,  but 
sometimes  rather  slowly,  and  remains  at  about  101°  F.  for  one,  two 
or  three  days,  after  which  it  gradually  returns  to  normal.  Subse- 
quent elevations  of  temperature  are  possibly  associated  with  new 
foci  of  infection  or  of  absorption  of  toxins.  The  approach  of  the 
temperature  to  the  normal  may  continue  in  spite  of  the  development 
of  severe  complications.     The  sudden  fall  of  the  temperature  to 


184  Appendicitis 

the  normal  or  subnormal  must  not  be  looked  upon  as  a  favorable 
sign.  It  is  very  often  a  sign  of  the  rapid  progress  of  gangrene  or 
the  rupture  of  an  appendix  or  peri-appendicular  abscess.  When 
following  gangrene  or  perforation  of  the  appendix  a  peri-appendic- 
ular abscess  forms,  there  is  usually  a  rise  in  temperature,  up  to 
104°  or  105°  F.  which  may  betoken  the  existence  of  some  com- 
plication due  to  spreading  infection  or  sepsis,  such  as  septic  phlebitis 
or  abscess  of  the  liver.  Under  these  circumstances  it  soon  becomes 
fluctuating,  irregular  and  associated  with  other  unmistakable  signs 
of  sepsis.  Hyperpyrexia  of  marked  degree  occurring  as  an  initial 
symptom  in  appendicitis  and  continuing  unabated  is  a  most  grave 
sign.  It  occurs  in  severe  and  fulminating  cases,  particularly  of  the 
streptococcic  variety  (Hann)  and  renders  the  prognosis  bad. 

The  pulse  rate  is  of  just  as  little  diagnostic  value  as  the  tempera- 
ture. As  a  general  rule  it  may  be  stated  that  a  fluctuation  in  one 
is  usually  associated  with  a  similar  one  in  the  other.  The  character 
of  the  pulse,  however,  is  of  considerable  value  with  reference  to  the 
gravity  of  the  attack  and  the  prognosis.  If  the  pulse  be  strong,  of 
good  volume,  regular  and  the  rate  proportionate  to  the  temperature, 
the  outlook  is  favorable.  Reversed  conditions  have  the  opposite 
meaning.  Just  as  low  temperature  is  often  deceptive  so  also  is 
bradycardia.  Indeed  Kahn  has  asserted  that  a  very  slow  pulse  in 
appendicitis  is  almost  always  a  sign  of  gangrene.  This  statement 
is  almost  too  strong,  yet  many  cases  occur  in  which  the  association 
of  the  two  conditions  is  noted.  A  sudden  change  for  the  worse  in 
the  pulse  alters  our  prognosis,  but  often  comes  too  late  to  be  of 
value  in  altering  the  treatment. 

Chills  are  among  the  rarer  manifestations  of  general  infection 
in  appendicitis.  Their  occurrence  at  the  onset  of  the  attack, 
particularly  when  accompanied  by  an  initial  high  temperature  is 
almost  pathognomonic  of  gangrene  of  the  appendix.  Later  in  the 
course  of  the  disease  they  may  indicate  some  complication  of  a 
septic  nature,  but  care  must  be  taken  to  differentiate  them  from 
the  purely  neurotic  manifestations  in  some  patients.  The  develop- 
ment of  peri-appendicular  abscess  is  not  accompanied  by  chills. 

Icterus  either  before  or  after  operation,  when  not  directly  due 
to  a  liver  complication  is  a  manifestation  of  severe  and  general 
toxaemia.     According   to   Reichel,   who   has   exhaustively   studied 


Symptomatology  185 

the  subject,  it  is  a  sign  of  the  gravest  importance.  In  my  own 
experience  I  have  but  rarely  noted  it,  except  in  hepatic  infections. 

Respiration  may  be  affected  in  appendicitis  either  because  of 
a  voluntary  inaction  of  the  abdominal  muscles  or  by  the  presence  of 
marked  tympanites  or  general  peritonitis,  in  which  we  find  the 
breathing  almost  entirely  costal.  Occurring  independently  of 
local  conditions  rapid  breathing  is  a  sign  of  toxaemia  or  of  some 
embolic  pulmonary  condition.  In  children  particularly  it  may  at 
times  render  difficult  the  differentiation  between  an  acute  abdominal 
and  an  acute  intra-thoracic  lesion. 

Changes  in  the  urine  in  acute  appendicitis  are  manifestations 
of  the  general  febrile  state  and  of  the  action  upon  the  kidneys  of 
the  toxins  generated,  and  also  may  in  part  be  due  to  the  fever. 
The  urine  is  usually  diminished  in  amount,  of  high  specific  gravity, 
dark  in  color  and  often  contains  albumin,  casts  and  increased  amount 
of  urobilin  and  indican.  We  really  have  an  acute  or  subacute  toxic 
nephritis,  which  may  at  times  be  very  severe.  Thus,  Hildebrahdt 
reports  a  case  of  appendicitis  complicated  by  such  severe  renal 
hgemorrhagic  nephritis  as  to  obscure  the  diagnosis.  I  have  records 
of  numerous  cases  in  which  the  urine  was  less  than  normal,  and 
contained  erythrocytes,  hyaline,  granular  and  epithelial  casts, 
desquamated  epithelium,  granular  debris,  etc.  In  most  of  these 
cases  the  urine  returned  to  normal  during  the  convalescence,  and 
this  may  be  expected  in  favorable  cases. 

Leucocytosis  is  present  in  the  majority  of  cases  of  appendicitis, 
and  may  be  classed  as  a  manifestation  of  infection.  Its  value  as 
regards  diagnosis,  prognosis,  and  indication  for  operation  is  dis- 
cussed in  another  chapter. 

The  general  condition  of  the  patient  varies  in  different  in- 
stances. In  the  early  hours  of  the  attack  there  is  a  general  facial 
expression  of  pain  and  considerable  anxiety.  Later,  with  the 
moderation  of  the  pain,  the  patient  remains  quiet  in  bed  and  favors 
the  right  side.  A  characteristic  posture  is  usually  assumed  in  that 
the  patient  prefers  the  dorsal  decubitus,  inclines  the  body  somewhat 
to  the  right,  flexes  the  right  thigh,  keeps  the  left  thigh  extended, 
demands  perfect  quiet,  and  resents  disturbance  in  the  desire  not 
to  provoke  or  to  intensify  the  pain.  Aside  from  the  general  expres- 
sion of  pain  and  anxiety  in  the  early  hours  of  the  attack,  the  facial 


1 86  Appendicitis 

expression  is  seldom  indicative  of  serious  disease.  As  the  lesions 
become  more  widespread  and  peri- appendicular  abscess  or  general 
peritonitis  develop,  the  expression  becomes  more  anxious,  and  a 
peculiar  serious  cast  of  countenance  supervenes^aa>5  abdominalis. 
In  severe  cases  of  sepsis  cyanosis  and  profuse  perspiration  some- 
times occur.  When  the  disease  is  advanced,  restlessness  may 
develop.  This,  if  marked,  particularly  in  children,  is  indicative 
of  severe  infection,  and  of  the  probable  presence  of  pus,  and  is  a 
very  unfavorable  symptom.  The  tongue  is  usually  furred;  if 
diffuse  peritonitis  occur,  the  tongue  may  become  dry,  and  sordes 
may  collect  upon  the  gums  and  teeth.  In  severe  cases  the  tongue 
may  become  fissured. 

The  subjective  symptoms  must  be  supplemented,  in  making  a 
diagnosis,  by  a  thorough  physical  examination  of  the  patient. 

Inspection  of  the  abdomen  may  reveal  more  or  less  bulging  of 
the  right  iliac  fossa.  In  the  early  stages  of  the  attack  this  is  uncom- 
mon; in  the  later  stages  it  may  be  due  to  peri-appendicular  abscess, 
to  muscular  rigidity  or  to  a  tympanitic  distention  of  adherent  intes- 
tines. It  is  rarely  due  to  a  non-suppurative  inflammatory  exudate 
and  serous  infiltration  of  the  abdominal  wall. 

A  general  distention  of  the  abdomen  is  not  infrequently 
observed  and  in  the  early  stages  of  the  disease  is  usually  due  to  the 
paralysis  of  the  intestine  because  of  infection,  obstinate  constipation 
with  resultant  accumulation  of  gases,  or  the  excessive  use  of  opium. 
In  a  few  cases  there  develops  on  the  first  day  of  the  attack,  a  general 
distention  and  some  diffuse  tenderness  of  the  abdomen,  usually 
subsiding  rapidly.  Richardson  points  out  that  it  is  possible,  by 
means  of  auscultation,  to  distinguish  between  the  distention  due  to 
accumulated  gas  and  that  due  to  paralysis  of  the  intestine  the 
consequence  of  infection;  the  sounds  of  the  peristaltic  action  of 
the  bowel  are  clearly  audible  in  the  former  condition,  but  are 
absent  in  the  latter.  Distention,  though  usually  general,  may 
sometimes  be  limited  to  the  right  side  of  the  abdomen,  as  a  result 
of  that  portion  of  the  bowel  contiguous  to  the  inflamed  area  alone 
being  affected.  This  local  distention  may,  upon  occasion,  become 
marked,  by  reason  of  the  still  functionating  intestine  forcing  a 
greater  or  less  quantity  of  gas  into  the  affected  portion.  As  is  to  be 
expected  the  distention  is  most  marked  when   the  peritonitis  is 


Symptomatology  187 

diffuse.  In  some  cases  of  diffuse  peritonitis,  however,  though  the 
intestines  are  more  or  less  distended,  the  abdomen  may  be  quite 
fiat  and  its  wall  rigid  and  hard.  Under  such  circumstances  there 
often  arise  most  unpleasant  symptoms  the  consequence  of  pressure 
from  below  upward  upon  the  thoracic  organs. 

By  palpation,  in  the  early  stages  of  an  acute  attack,  we  are 
usually  unable  to  detect  more  than  tenderness  in  the  right  iliac 
region  with  rigidity — of  which  mention  has  already  been  made 
when  discussing  the  three  cardinal  symptoms  of  the  disease.  In 
some  cases,  however,  we  can  recognize  by  rather  deep  palpation 
a  sense  of  resistance,  which  is  sometimes  distinctly  circumscribed, 
and  of  elongated,  cylindrical  outline.  This  may  with  reason  be 
ascribed  to  a  thickened  appendix,  a  fold  of  omentum,  band-like 
contraction  of  the  rectus  muscle,  or  some  possible  peri-appendicular 
exudate  of  a  non-suppurative  nature.  In  some  cases  such  is  the 
tenderness  over  the  region  of  the  appendix  that  even  moderately 
deep  palpation  is  impossible.  In  other  cases  the  rigidity  of  the 
abdominal  wall  precludes  satisfactory  palpation. 

On  the  other  hand,  in  addition  to  tenderness  and  rigidity  of 
the  abdominal  muscles,  palpation  may  reveal  a  rather  diffuse 
resistance  or  a  more  or  less  distinctly  circumscribed  swelling  or 
tumor  in  the  right  iliac  region.  The  tumor,  when  palpable,  is  of 
smooth  or  roundish  contour,  and  its  edges  are  usually  sloping. 
It  varies  in  size  in  different  cases.  It  is  sometimes  no  larger  than  an 
egg;  it  is  usually  as  large  as  a  lemon  or  a  small  orange;  it  is  rarely 
as  large  as  a  cocoanut.  It  generally  courses  parallel  with  Poupart's 
ligament  and  is  removed  a  short  distance  from  the  crest  of  the 
ilium.  When  large,  however,  it  may  reach  the  ilium,  and  may 
extend  upward  beyond  its  crest  and  beyond  the  median  line  of  the 
abdomen.  The  tumor  in  the  vast  majority  of  cases  is  immobile. 
It  is  generally  firm,  but  may  be  quite  soft;  in  some  cases,  particularly 
if  it  be  large,  it  may  present  distinct  fluctuation. 

The  conditions  upon  which  this  tumor  or  swelling  depends 
vary  somewhat  in  different  instances.  In  cases  unattended  by 
peri-appendicular  suppuration  it  is  due  to  the  thickening  and 
oedema  of  the  inflamed  tissues — the  appendix  itself,  possibly  the 
caecum  and  particularly  the  omentum;  to  peri-appendicular  serous, 
sero-fibrinous,  and  fibrinous  exudate;  to  inflammatory  alterations 


1 88  Appendicitis 

not  only  of  the  viscera,  but  also  of  the  parietal  peritoneum  of  the 
iliac  fossa  and  the  abdominal  wall;  and  in  some  cases  to  serous  and 
cellular  infiltration  of  the  transversalis  fascia  and  the  abdominal 
muscles.  In  the  majority  of  these  cases  the  size  of  the  swelling 
is  dependent  upon  the  amount  of  the  peri-appendicular  exu- 
date, which  at  times  is  excessive.  In  endeavoring  to  formulate 
an  opinion  as  to  the  cause  of  a  swelling  in  an  individual  case  it 
must  be  borne  in  mind  that  the  plastic  exudate  surrounding  an 
inflamed  appendix  may  be  3  cm.,  4  cm.,  or  5  cm.  in  thickness. 
As  a  consequence,  it  must  not  be  assumed  that  all  tumors,  even  if 
they  be  of  moderate  size,  have  within  them  a  purulent  focus.  Some 
even  very  large  swellings  develop  with  such  rapidity  and  become  so 
quickly  dissipated  that  it  is  impossible  to  hold  with  reason  that 
they  have  been  suppurative.  Such  exudates,  however,  are  very 
prone  to  become  purulent,  and  it  is  true  that  all  tumors  of  moderate 
and  large  size  are,  in  part  at  least,  composed  of  pus.  It  is,  of  course, 
in  cases  in  which  there  is  a  considerable  quantity  of  pus  that  fluctua- 
tion may  be  elicited.  I  have  observed  several  cases  in  which  a 
tumor  mass  has  been  simulated  by  excessive  muscular  rigidity  of 
the  lower  part  of  the  right  rectus. 

Berardinone  has  noticed  in  a  number  of  cases  the  sudden 
enlargement  of  a  single  lymph  node  near  the  external  abdominal 
ring  on  the  right  side,  above  Poupart's  ligament.  This  has  not 
occurred  in  the  vast  majority  of  my  cases  and  I  consider  it  insignifi- 
cant as  a  symptom  of  appendicitis. 

Percussion  is  of  subordinate  importance  in  the  diagnosis.  In 
the  event  of  a  swelling  or  tumor  forming  in  the  right  iliac  fossa  the 
note  is  generally  dull  and  high  in  pitch.  Such  note  may,  however, 
be  due  to  causes  other  than  appendicitis  with  peri-appendicular 
peritonitis,  and  these  morbid  conditions  may  develop  without  the 
occurrence  of  dullness  on  percussion.  Even  large  peri-appendicular 
abscesses  may  exist  with  a  tympanitic  note  in  the  right  iliac  fossa, 
particularly  if  gas  has  been  generated  within  the  abscess  cavity. 
Such  note  will  occur,  for  instance,  if  a  coil  of  intestine  overlie  the 
abscess.  A  dull  note,  of  tympanitic  quality  and  high  in  pitch,  may 
occur  in  the  absence  of  an  abscess  if  there  be  excessive  rigidity  of 
the  abdominal  wall.  At  times  there  is  found  an  area  of  tympany 
intervening  between  the  ilium  and  the  area  of  dullness.     This  is 


Symptomatology  189 

generally  due  to  the  presence  in  this  region  of  the  caecum— the 
abscess  being  situated  toward  the  median  line.  Mangoldt  has 
described  the  occurrence  in  cases  of  retro-caecal  abscess  when  this 
pushes  the  caecum  and  ileum  against  the  anterior  abdominal  wall 
of  a  peculiar  percussion  note  at  the  outer  edge  of  the  right  rectus 
muscle  over  the  caecum.  He  describes  it  as  a  cracked  pot  sound  or 
"bruit  de  pot  fele"  and  ascribes  it  to  the  disturbance  of  the  fluid 
contents  of  the  caecum. 

Auscultation  reveals  little  of  importance  in  the  diagnosis. 
Reference  has  already  been  made  to  its  value  in  distinguishing 
between  distention  due  to  accumulated  intestinal  gas  and  that  due 
to  paralysis  of  the  intestine  the  consequence  of  infection.  Manna- 
berg  and  Nothnagel  have  drawn  attention  to  an  accentuation  of  the 
second  pulmonic  sound  of  the  heart  in  appendicitis,  but  do  not 
explain  the  cause  of  the  phenomenon.  Accentuation  of  the  second 
pulmonary  sound  has  been  observed  in  biliary  colic  and  is  explained 
on  the  hypothesis  that  there  is  reflex  constriction  of  the  pulmonary 
arteries.  Auscultatory  percussion  by  means  of  the  stethoscope  or 
phonendoscope  may  assist  in  outlining  the  tumor. 

Leucocytosis  has  been  observed  in  a  number  of  cases  of  appen- 
dicitis. Its  value  as  regards  diagnosis,  prognosis,  and  indication  for 
operation  are  discussed  in  another  chapter. 

CHRONIC  APPENDICITIS. 

Chronic  appendicitis  is  probably  the  most  common  of  all  abdom- 
inal diseases.  Pathologic  examination  demonstrates  that  it  is  rare 
for  an  adult  to  possess  an  appendix  that  is  normal  in  every  respect. 

Of  500  appendices  removed  as  an  incidental  procedure  during 
the  course  of  abdominal  or  pelvic  operations  317  or  63.4  per  cent, 
showed  chronic  catarrhal  or  interstitial  lesions  and  71  or  14.2  per 
cent,  were  completely  obliterated.  There  can  be  no  question  that 
such  lesions  are  the  result  of  previous  acute  or  subacute  attacks  of 
inflammation  or  of  mild  irritative  influences  acting  for  a  longer 
period.  In  general  it  may  be  stated  that  the  appendix  when  once 
attacked  by  inflammation  becomes  more  and  more  susceptible. 
When  complete  obliteration  of  the  lumen  finally  occurs,  however, 
the  susceptibility  to  disease  diminishes  so  markedly  as  to  constitute. 


I  go  Appendicitis 

for  all  practical  purposes,  a  cure.  If  the  obliterating  process  involves 
only  a  small  segment  of  the  appendix,  in  othei  words  if  a  stricture 
is  formed  and  especially  if  that  stricture  be  near  the  proximal  end, 
we  have  a  mechanism  for  the  retention  of  faecal  material  and  the 
products  of  secretion  and  desquamation  that  give  5  rise  to  more  or 
less  constant  trouble  and  renders  the  danger  of  an  acute  attack  ever 
present.  Adhesions  and  kinks  tend  to  excite  congestion  and 
inflammation  of  the  appendix.  Thickening  and  distortion  of  its 
walls  interfere  with  its  peristalsis,  :ause  stagnation  and  predispose 
to  renewed  infection.  Faecal  concretions  and  calculi  are  a  constant 
source  of  irritation,  often  resulting  in  chronic  ulceration  of 
the  mucous  membrane  and  more  or  less  marked  interstitial  in- 
flammation. 

The  pathologic  changes  at  the  bottom  of  the  symptoms  of  chronic 
appendicitis  aie  legion  and  the  symptomatology  is  correspondingly 
varied.  At  the  present  time  we  are  not  able  to  correlate  any  special 
combination  of  chronic  symptoms  with  definite  pathologic  lesions 
with  sufficient  constancy  to  enable  us  to  surmise  before  operation 
the  precise  pathologic  lesion  of  the  appendix.  It  is  agreed  practically 
by  all,  however,  that  the  existence  of  symptoms  referable  to  the 
appendix  is  sufficient  indication  for  operation.  Could  the  diagnosis 
of  chronic  appendicitis  be  made  more  often  and  operation  performed 
during  that  stage  the  mortality  of  the  acute  disease  would  be  reduced, 
since  the  evidence  of  pathologic  examinations  and  of  careful  histories 
in  acute  appendicitis  tend  to  show  that  in  the  great  majority  of  cases 
the  acute  process  is  implanted  upon  a  chronic  stage  of  the  disease. 

Clinically  chronic  appendicitis  may  be  classed  broadly  in  three 
divisions,  relapsing  appendicitis,  recurring  appendicitis  and 
chronic  appendicitis  with  referred  symptoms. 

Relapsing  appendicitis  is  one  in  which  an  appendicular  inflam- 
mation is  always  present  but  only  shows  itself  as  an  acute  lesion 
after  certain  intervals  of  comparative  quiescence.  The  diagnosis  of 
relapsing  appendicitis  is  not  usually  difficult.  We  have  a  history  of 
one  or  more  acute  attacks,  with  continued  tenderness  over  the  appen- 
dix and  perhaps  some  of  those  digestive  disturbances  later  to  be 
discussed  in  a  consideration  of  simple  chronic  appendicitis.  The 
history  of  acute  attacks  alone,  if  they  be  properly  diagnosed  by  the 
medical  attendant  is  sufficient  to  establish  the  diagnosis  regardless 


Symptomatology  igi 

of  any  physical  evidences  of  a  definite  appendiceal  lesion,  but  does 
not  establish  firmly  the  diagnosis  of  the  appendicitis  as  relapsing 
instead  of  recurrent.  This,  however,  is  not  important  as  regards 
the  line  of  treatment  to  be  adopted. 

A  recurrent  appendicitis  is  one  in  which  the  acute  attacks  are 
said  to  be  separated  by  periods  of  perfect  health.  I  am  very  doubt- 
ful whether  an  acute  or  even  a  subacute  attack  of  appendicitis 
ever  runs  its  course  to  recovery  leaving  a  perfectly  healthy  appendix, 
pathologically  considered.  I  believe  also  that  it  is  most  likely 
that  more  cases  are  relapsing  than  recurring — that  is  to  say,  that 
in  many  instances  where  the  quiescent  appendicitis  does  not  give 
symptoms  directly  referred  to  the  appendix  there  are  nevertheless 
other  portions  of  the  alimentary  tract  affected  by  it  and  causing 
symptoms  referred  to  them  individually.  That  recurrences  are  very 
frequent  is  indicated  by  various  statistics.  Thus  Nothnagel  gives 
the  percentage  of  recurrences  in  his  experience  as  i6  per  cent.; 
Rotter  as  21  per  cent.;  Sonnenburg  as  32  per  cent.;  and  Sahli,  from 
a  collective  investigation  of  4593  cases  from  private  practice,  as 
20.8  per  cent.  Of  460  of  my  own  cases,  recurrences  were  noted  in 
312  (67.8  per  cent.).  The  vast  majority  of  recurrences  develop 
within  the  first  six  months;  there  are  less  within  the  succeeding  six 
months.  During  the  following  years  the  likelihood  of  recurrence 
becomes  gradually  less;  recurrence  may  nevertheless  occur  after 
a  great  number  of  years.  The  number  of  recurrences  that  a  patient 
may  suffer  is  variable.  Of  the  312  patients  previously  referred  to, 
89  had  two  attacks,  52  had  three  attacks,  30  had  four  attacks,  18 
had  five  attacks,  16  had  six  attacks,  6  had  seven  attacks,  2  had  eight 
attacks,  2  had  nine  attacks,  4  had  ten  attacks,  i  had  twelve  attacks, 
2  had  sixteen  attacks,  2  had  twenty  attacks.  The  number  of  attacks 
that  the  remainder  had  is  not  known. 

The  diagnosis  of  chronic  appendicitis  is  usually  clear  to  those 
who  are  in  a  position  to  see  large  numbers  of  these  cases  but  often 
it  proves  to  be  a  stumbling  block  to  the  practitioner  whose  experience 
is  necessarily  limited  to  the  confines  of  his  practice.  If  he  will 
remember  that  at  least  nine-tenths  of  all  symptoms  referable  to 
the  right  iliac  fossa  are  due  to  disease  of  the  appendix  fewer  cases 
will  be  overlooked.  The  plainer  cases  give  a  history  of  more  or 
less  constant  distress  or  pain  referred  to  the  region  of  the  appendix 


192  Appendicitis 

and  examination  reveals  definite  soreness  on  deep  palpation  over  the 
organ.  Even  in  the  absence  of  any  history  of  acute  attacks  a  diag- 
nosis may  be  made  with  almost  invariable  accuracy  on  this  combina- 
tion alone.  The  type  and  severity  of  the  pain  may  be  exceedingly 
variable.  It  may  be  sharp  and  stabbing,  dull  and  aching,  burning, 
colicky,  constant,  remittent,  intermittent  or  practically  constant.  It 
may  or  may  not  excite  nausea.  Intestinal  flatulence  is  a  common 
symptom.  Slight  stiffening  of  the  overlying  muscles  as  determined  by 
light  careful  palpation  is  a  valuable  confirmatory  sign.  Occasionally 
a  thickened  or  distended  appendix  may  be  palpated  but  less  reliance 
should  be  placed  on  this  than  on  a  deep  soreness  on  pressure  which 
can  usually  be  elicited. 

The  simplest  variation  from  this  standard  type  is  that  which  is 
consequent  upon  an  abnormally  situated  appendix.  It  is  well 
known  that  the  caecum  is  variable  in  its  situation.  The  embryonic 
rotation  of  the  caecum  may  be  interrupted  in  various  locations.  It 
may  be  unusually  high,  low  or  even  in  exceptional  instances  upon 
the  left  side.  The  appendix  also,  as  previously  dwelt  upon,  maybe 
long  or  short  and  may  point  in  all  directions  of  the  compass.  A 
high  appendix  may  give  symptoms  that  correspond  more  to  the 
location  of  the  gall-bladder,  the  duodenum  or  the  kidney.  A  low 
appendix  when  inflamed  sometimes  irritates  the  bladder,  rectum  or 
internal  genitalia.  The  retro-caecal  appendix  at  times  gives  pain  in 
the  loin  or  back  and  movement  of  the  psoas  muscle  causes  pain  by  dis- 
turbing the  inflamed  member.  When  it  chances  to  lie  in  proximity  to 
the  ganglia  or  nerve  trunks  supplying  the  inguinal  region  or  thigh  the 
pain  may  be  referred  to  the  terminals  of  these  nerves.  Exercise  com- 
monly aggravates  the  symptoms  in  the  retro-caecal  appendix  and  at 
times  in  other  varieties.  The  soreness  elicited  in  these  cases  is  also 
shifted  to  correspond  to  the  location  of  the  appendix.  In  these  cases 
a  careful  history  eliciting  perhaps  an  attack  characterized  by  pain  of 
intestinal  character,  such  as  colic  or  nausea,  is  important.  Elimina- 
tion of  disease  of  other  organs,  which  from  their  location  may  be  sus- 
pected, also  aids  in  confirming  the  suspicion  of  disease  of  the  appen- 
dix. Stone  in  the  ureter  should  always  be  considered  in  obscure  cases 
of  pain  in  the  right  iliac  fossa.  I  have  observed  a  number  of  cases 
which  from  the  history  alone  could  not  be  distinguished  and  in 
some  instances  operation  had  been  done  upon  the  appendix  without 


Symptomatology  193 

relief  of  symptoms  which  were  subsequently  found  to  be  due  to 
ureteral  calculus.  The  X-ray,  catheterization  of  the  ureters  and 
careful  examination  of  the  urine  will  usually  avoid  the  mistake.  A 
history  of  true  renal  colic  is  not  always  to  be  obtained  in  these  cases. 
Constipation  is  the  rule  in  chronic  appendicitis  but  a  history  of 
alternating  diarrhoea  and  constipation  is  obtained  in  not  a  few  cases. 

Careful  consideration  of  these  points  supplemented  by  a  physical 
examination  of  all  cases  that  complain  of  abdominal  pain  will 
usually  clear  up  the  diagnosis  of  these  types  of  chronic  appendicitis. 

Appendicitis  with  symptoms  that  are  entirely  referred  is 
much  more  diiBcult  and  may  be  impossible  of  clinical  diagnosis. 

I  have  already  emphasized  the  fact  that  a  normal  appendix  is  a 
rarity  in  the  adult  and  that  pathologists  and  clinicians  are  practically 
agreed  that  these  departures  from  the  normal  are  the  result  of 
previous  inflammations.  While  it  is  true  that  in  many  instances  we 
are  yet  unable  to  develop  any  history  of  symptoms  referable  to  the 
appendix  in  cases  that  give  unmistakable  pathologic  evidence  of 
disease,  yet  there  is .  at  present  more  than  a  suspicion  that  the  situa- 
tion is  comparable  to  that  of  gall-bladder  disease  which  was  formerly 
thought  to  give  rise  to  no  symptoms  in  the  majority  of  cases.  Just  as 
"  symptomless"  gall-stones  and  cholecystitis  are  shown  to  be  a  myth 
by  careful  analysis  of  cases,  so  in  my  opinion  symptomless  chronic 
appendicitis  will  be  found  to  have  no  basis  in  fact  but  only  in  our 
failure  to  connect  cause  with  effect.  That  chronic  appendicitis 
may  give  no  localizing  symptoms  or  signs  and  yet  cause  distressing 
"indigestion"  may  now  be  regarded  as  proved.  These  symptoms 
are  commonly  referred  to  the  epigastrium  and  are  confounded  with 
chronic  gastritis,  gastric  or  duodenal  ulcer,  gall-bladder  disease  or 
pancreatitis.  The  symptoms  are  extraordinarily  varied.  Maun- 
sell's  definition  of  appendicular  dyspepsia  may  be  quoted,  "  It  is  a 
group  of  symptoms  and  perhaps  signs,  which  point  so  strongly  to 
organic  gastric  or  duodenal  disease  that  it  is  only  by  most  careful 
examination  or  by  the  supervention  of  definite  appendicular  symp- 
toms that  a  correct  diagnosis  is  probable."  I  could  instance  a  large 
number  of  cases  in  which  I  have  operated  in  the  expectation  of  finding 
upper  abdominal  disease  only  to  find  chronic  appendicitis  the  sole 
lesion  and  have  had  the  pleasure  of  seeing  these  cases  recover 
entirely  from  their  former  symptoms  after  removal  of  the  appendix. 
13 


194  Appendicitis 

If  this  occurred  only  in  cases  of  a  neurotic  character  it  might  be  ex- 
plained on  the  basis  of  suggestion.  If  it  were  an  uncommon  experi- 
ence it  might  be  only  a  coincidence  but  when  it  occurs,  as  it  does,  so 
commonly  in  the  experience  of  every  active  abdominal  surgeon  as 
scarcely  to  excite  remark,  the  conclusion  is  irresistible  that  a  dis- 
eased appendix  may  by  reflex  action  influence  the  function  of 
organs  at  a  distance  in  such  a  manner  as  to  cause  marked  disturbance 
of  that  function  and  consequent  symptoms.  It  has  frequently 
happened  also  that  cases  have  come  to  operation  for  chronic  appen- 
dicitis whose  entire  previous  history  was  that  of  upper  abdominal 
disease  until  a  final  attack  perhaps  more  severe  has  revealed  the 
existence  of  a  diseased  appendix,  removal  of  which  has  demon- 
strated the  presence  of  long-standing  inflammatory  changes.  The 
type  of  appendix  which  is  most  commonly  associated  with  referred 
gastric  symptoms  is  that  which  contains  one  or  more  appendicular 
calculi  in  its  distal  portion. 

It  must,  of  course,  be  remembered  that  disease  of  the  upper 
abdominal  viscera  may  coexist  with  chronic  appendicitis.  There  is 
considerable  evidence  for  the  belief  that  appendicitis  is  one  of  the 
causes  of  infection  of  the  biliary  tract  and  the  suggestion  is  made,  not 
without  some  show  of  reason,  that  pyloric  and  duodenal  ulcer  are  at 
times  the  more  or  less  direct  result  of  chronic  appendicitis.  Haemat- 
emesis  has  been  met  with  not  a  few  times  without  demonstrable 
disease  of  the  stomach  but  in  association  with  chronic  appendicitis. 

The  phenomenon  of  pylorospasm  has  been  definitely  connected 
with  some  cases  of  chronic  disease  of  the  appendix.  The  so-called 
secretory  neuroses  also  seem  at  times  to  be  dependent  upon  the  same 
cause.  It  is  not  difficult  to  realize  that  reflex  disturbance  of  the 
functions  of  the  stomach  by  appendicular  disease  may  easily  lead  to 
erosions  and  finally  gross  ulceration.  Finally,  the  close  functional 
interdependence  of  the  gastro-duodeno-hepato-pancreatic  system 
permits  ready  derangement  of  any  one  of  these  organs  by  vicious 
functioning  of  any  one  of  the  members  of  the  system  and  the  creation 
of  a  loais  minoris  resistenficB  for  the  implantation  of  infection. 
It  is  therefore  readily  seen  that  the  diagnosis  of  chronic  appendicitis 
of  this  type  may  be  extraordinarily  diflScult  and  even  impossible 
from  a  clinical  standpoint.  It  also  points  the  suggestion  that  indi- 
gestion of  any  type  whatsoever  should  lead  to  the  development  of  a 


Symptomatology  195 

careful  history  bearing  upon  the  possibility  of  appendicitis  and  should 
necessitate  careful  and  repeated  examination  of  the  region  of  the 
appendix. 

The  simulation  of  pelvic  disease  in  women  and  the  influence  of 
chronic  appendicitis  and  appendiceal  adhesions  in  the  pelvic 
disorders  of  women  have  received  attention  in  another  chapter. 

Taking  all  facts  into  consideration  the  diagnosis  of  chronic 
appendicitis  is  found  to  be  easy  only  when  there  is  a  definite  history 
of  acute  exacerbations,  otherwise  its  symptoms  are  most  diverse  and 
baffling  and  it  should  always  be  considered  as  a  possibility  however 
strongly  the  symptoms  may  point  to  organic,  gastric,  duodenal, 
hepatic  or  pancreatic  disease. 

Removal  of  the  appendix  is  the  only  treatment  to  be  recom- 
mended for  any  form  of  recognizable  chronic  appendicitis.  Only 
the  strongest  contraindication  to  operation  should  be  permitted  to 
weigh  in  the  scale  against  operation,  the  only  alternative  being 
general  medical  hygiene  which  can  accomplish  little,  if  anything, 
in  the  majority  of  cases. 

SUMMARY. 

There  is  no  constant  relationship  between  the  symptomatology 
and  the  pathological  alterations. 

Of  acute  appendicitis  there  are  "three  cardinal  symptoms" 
— pain,  tenderness,  and  rigidity  of  the  abdominal  wall. 

The  pain  is  at  first  colicky,  and  is  referred  to  the  umbilical 
region;  later,  it  becomes  localized  at  the  site  of  the  appendix. 

Tenderness  on  pressure  is  always  present,  and  is  sometimes 
best  elicited  by  rectal  or  vaginal  examination.  The  point  of  greatest 
tenderness  is  usually  over  the  site  of  the  appendix. 

The  rigidity  of  the  abdominal  wall  is  usually  right-sided.  It 
follows  the  localization  of  the  pain,  and  is  most  marked  over  the  in- 
flamed area. 

Vomiting  is  common  at  the  onset  of  the  attack.  It  desists  in 
favorable  cases.     Its  continuance  is  an  unfavorable  symptom. 

In  chronic  appendicitis  the  history  is  important.  Localized 
pain  and  tenderness  are  the  most  constant  symptoms.  Palpation  is 
a  most  valuable  means  of  diagnosis. 


APPENDICITIS  IN  CHILDREN. 

The  frequency  of  appendicitis  in  early  life  has  in  the  past  been 
underestimated.  Our  experience  has  shown  that  it  is  by  no  means 
uncommon  in  childhood  and  not  rare  in  infancy.  Indeed,  were  the 
diagnostic  difficulties  in  infants  not  so  great  it  would  be  found  that 
many  cases  of  obstinate  and  severe  gastro-intestinal  disorders  had 
their  origin  in  but  a  small  portion  of  the  intestinal  tract — the  appen- 
dix A'ermiformis. 

There  is,  however,  abundant  evidence  that  appendicitis  increases 
in  frequency  from  birth  to  puberty,  and  that  it  is  far  less  frequent  in 
childhood  than  in  early  adult  life.  It  is  difficult  to  estimate  the 
comparative  frequency  of  appendicitis  in  childhood  and  in  adult  life, 
not  only  because  of  the  difficulty  of  its  diagnosis  in  the  very  young 
but  also  because  it  is  difficult  to  obtain  absolutely  corresponding 
figures  of  hospitals  receiving  either  only  adults  or  only  children. 
'  In  the  six  years  ending  December  31,  1910,  there  were  operated 
1970  cases  of  acute  appendicitis  in  the  German  Hospital  and  468 
cases  of  acute  appendicitis  in  children  in  the  Mary  J.  Drexel  Home 
which  receives  all  cases  of  sickness  in  children  under  fifteen  years  of 
age  under  the  care  of  the  affiliated  institution.  During  the  same 
period  2100  cases  of  chronic  appendicitis  were  operated  on  at  the 
German  Hospital  in  comparison  to  130  cases  at  the  Mary  J.  Drexel 
Home.  In  a  series  of  1000  consecutive  cases  of  appendicitis  McCosh 
found  153  in  children  under  fifteen  years.  They  were  distributed  as 
follows : 

Up  to  5  years i7>  i-7  per  cent. 

5  to  10  years 51,  5.1  per  cent. 

10  to  15  years 85,  8.5  per  cent. 

In  a  corresponding  series  of  500  cases  of  appendicitis  at  the 
Mary  J.  Drexel  Home  compiled  by  Dr.  H.  C.  Deaver  there  were: 

Up  to  5  years 40,  8    per  cent. 

5  to  10  years •. 180,  35  per  cent. 

10  to  15  years 280,  56  per  cent. 

196 


Appendicitis  in  Children  197 

Under  five  years  we,  as  a  rule,  find  the  disease  quite  rare  in  infants. 
Of  the  seventeen  cases  reported  by  McCosh  under  five  years,  three 
occurred  in  children  from  one  to  two  years  old;  one  from  two  to 
three  years;  seven  from  three  to  four  years  and  six  from  four  to  five 
years. 

Early  cases  of  appendicitis  have  been  reported  by  Bamberg  in 
an  infant  five  weeks  old;  by  Blumer  and  Shaw  in  one  of  seven  weeks 
old;  and  by  Dennis  and  Goyens  in  two  infants  six  weeks  old.  Dun 
of  Glasgow  in  an  extended  series  found  none  under  twelve  months 
old.  The  case  reported  by  Dixon  of  appendicular  hernia  in  which 
there  was  a  gangrenous  appendix  in  the  sac  of  a  strangulated  in- 
guinal hernia  may  have  been  one  of  primary  appendicitis. 

The  rarity  of  appendicitis  under  two  years  of  age  may  be  explained 
by  several  facts.  In  the  first  place  the  anatomical  configuration  of 
the  parts  does  not  so  markedly  predispose  to  imperfect  drainage  and 
to  congestion  as  it  does  in  later  life.  The  appendix  is  relatively 
larger,  the  drainage  is  therefore  better,  obstruction  to  the  lumen 
being  of  more  unusual  occurrence;  and  the  caecum  is  as  a  rule  situated 
higher  in  the  abdominal  cavity,  there  being  less  tendency  toward 
stagnation  in  the  radicals  which  carry  the  blood  from  the  appendix 
to  the  superior  mesenteric  vein.  Moreover,  the  infant's  usual 
position  is  either  supine  or  prone,  and  this  may  possibly  tend  to 
prevent  congestion.  A  more  important  reason  is  the  character  of 
the  diet,  which,  being  chiefly  fluid,  renders  the  stools  soft,  and  is  not 
so  apt  to  cause  serious  indigestion  as  is  the  food  partaken  of  by  older 
children.  The  bowels  are  also  emptied  oftener  in  infants,  and  thus 
the  colon,  which  becomes  more  fixed  as  age  advances,  is  not  sub- 
jected to  such  strain.  Very  possibly  many  cases  of  appendicitis  in 
infancy  are  overlooked. 

As  to  sex,  we  have  found  as  in  adults,  a  predominance  of  males 
in  the  appendicitis  of  children.  Thus  of  500  cases  at  the  Mary  J. 
Drexel  Home  315  were  males  and  185  females.  This  is  a  slightly 
greater  proportion  of  females  than  other  statistics  have  shown. 

The  pathological  anatomy  of  appendicitis  in  children  varies 
somewhat  from  that  in  adults.  Suppuration,  localized  in  the  vast 
majority  of  instances,  is  much  more  usual  than  in  adults.  Thus 
of  403  cases  of  acute  appendicitis  in  the  500  pre\iously  quoted, 
243  had  local  abscess,  12  had  general  peritonitis  and  43  had  diffuse 


198  Appendicitis 

peritonitis.  The  fact  that  in  39  instances  the  abscesses  were 
multiple  seems  to  indicate  that  multiple  abscess  is  more  common  in 
children  than  in  adults.  It  must  not  be  forgotten,  however,  that  the 
frequency  of  abscess  may  be  due  in  large  measure  to  the  fact  that  the 
cases  are  not  diagnosed  sufficiently  early. 

As  to  the  appendix  itself  it  appears  from  the  statistics  of  various 
investigators  and  from  our  own  that  perforation  and  gangrene  or 
either  condition  are  found  in  about  the  same  percentage  of  cases  as 
in  adults.  According  to  Riedel  faecal  concretions  are  more  common 
in  children  than  in  adults  and  strictures  of  the  appendix  are  rarer 
in  children  than  in  adults.  It  is  probable  that  recurrences  in  children 
are  far  more  common  than  is  generally  supposed  and  the  difficulty  of 
obtaining  a  correct  anamnesis  makes  our  statistics  upon  this  sub- 
ject unreliable. 

The  lesions  in  the  appendix  itself  are  those  of  acute  appendicitis 
at  any  age  and  have  been  fully  described  in  the  chapter  on  pathology. 

The  S3miptomatology  of  appendicitis  in  childhood  is  in  many 
ways  divergent  from  that  in  adults.  Young  children  are  unable 
to  make  themselves  understood  and  we  have  only  the  objective 
signs  to  guide  us.  And  even  in  older  children  it  is  most  difficult  to 
obtain  a  correct  history  as  children  are  often  led  by  the  questions 
asked  by  parents  and  others  to  make  statements  contrary  to  facts. 

Pain,  tenderness  and  rigidity  are  again  the  cardinal  symptoms. 
It  may  be  most  difficult  to  distinguish  the  pain  from  colic  or  other 
forms  of  pain  caused  by  abdominal  disease.  Abdominal  pain  with 
vomiting  may  be  but  the  forerunner  of  one  of  the  acute  exanthemata. 
We  have  lately  had  occasion  to  see  such  an  instance  occurring  in  an 
adult.  The  patient  was  seen  by  a  surgeon  and  after  a  hasty  ex- 
amination operated  upon.  The  appendix  was  normal  but  the 
day  following  the  operation  the  typical  rash  of  measles  made  its 
appearance. 

The  fever  in  appendicitis  in  children  is  apt  to  be  higher  than 
in  adults,  children  in  all  cases  showing  greater  variations  of  tempera- 
ture for  corresponding  pathological  conditions.  According  to 
McCosh  and  our  own  experience  persistent  and  excessively  high 
fever  favors  the  existence  of  gastro-enteritis  rather  than  appendicitis. 
Vomiting  is  often  marked  and  persistent.  Dun  of  Glasgow  has 
called  attention  to  the  frequency  of  diarrhoea  in  his  cases  of  appendi- 


Appendicitis  in  Children  199 

citis  in  children.  While  it  is  by  no  means  unknown  to  find  diarrhoea 
in  a  child  having  appendicitis  it  is  not  common  and  hardly  to  be 
regarded  as  a  point  in  favor  of  the  diagnosis  of  appendicitis.  Ten- 
derness on  rectal  examination  is  also  mentioned  by  Dun  as  being 
commonly  found  in  appendicitis  of  children.  This  may  be  ac- 
counted for  by  the  frequency  of  pelvic  inflammation  as  a  result  of 
appendicitis  in  children,  but  cannot  be  considered  as  a  sign  to  be 
observed  in  the  majority  of  instances.  This  leads  us  to  mention 
that  rectal  examination  should  never  be  neglected  when  we  suspect 
appendicitis  in  a  child  as  it  is  of  the  greatest  importance  both  in  the 
diagnosis  and  differentiation  of  the  disease. 

On  the  whole  the  onset  of  acute  appendicitis  in  a  child  comes 
with  suddenness  and  severity.  The  patient  gives  every  evidence 
of  being  quite  ill  and  even  comparatively  mild  lesions  give  marked 
reaction  in  temperature,   pulse  and  leucocytosis. 

The  differential  diagnosis  is  often  a  matter  of  some  diflSculty. 

Gastro-enteritis  with  colic  must  be  eliminated.  McCosh  has 
mentioned  continual  hyperpyrexia  as  favoring  this  diagnosis  rather 
than  that  of  appendicitis.  In  colic  and  gastro-enteritis  vomiting 
is  not  usually  so  persistent  as  in  appendicitis  while  purging  is  usually 
more  marked.  There  may  be  abdominal  distention  but  rigidity  is 
not  a  marked  feature.  Even  the  voluntary  rigidity  in  infants  relaxes 
far  more  easily  than  that  which  takes  place  in  an  effort  to  protect 
an  inflamed  appendix.  Localized  and  severe  tenderness  over  the 
appendiceal  area  points  to  appendicitis.  While  in  gastro-enteritis 
there  may  be  a  vague  tenderness  in  the  right  iliac  fossa  it  never  has 
the  character  encountered  on  palpation  over  an  inflamed  peritoneal 
area. 

Next  in  importance  in  the  differential  diagnosis  is  intussuscep- 
tion, a  not  very  infrequent  condition  in  childhood.  While  very 
early  in  appendicitis  we  may  have  the  formation  of  a  mass  it  rarely 
takes  on  the  definite  contour  and  peculiar  consistency  of  bowel  in 
which  intussusception  has  occurred.  The  tenesmus  associated  with 
intussusception  may  be  mimicked  in  appendicitis,  although  this  is 
hardly  true  of  the  constant  painful  discharge  of  mucus  and  blood 
from  the  rectum  which  we  have  in  the  former  condition.  Pain 
followed  by  vomiting  ushers  in  the  intussusception  as  well  as  appen- 
dicitis.    Intussusception  is,  however,  rare  in  older  children,  the 


200  Appendicitis 

pain  is  paroxysmal,  early  collapse  is  common,  and  the  evidences 
of  obstruction  soon  set  in.  In  spite  of  these  differences  in  the  symp- 
tomatology the  differential  diagnosis  between  the  two  conditions 
may  be  difficult. 

Diaphragmatic  pleurisy  and  basal  pneumonia  in  children  often 
give  symptoms  which  may  be  confused  with  those  of  acute  appen- 
dicitis. Sudden  onset  with  pain,  vomiting  and  a  chill  may  occur 
in  appendicitis  just  as  in  pleurisy  or  pneumonia,  and  the  pain  result- 
ing from  a  thoracic  condition  is  often  at  first  referred  to  the  abdomen, 
oftenest  high  in  the  upper  quadrant,  but  occasionally  seemingly 
localized  in  the  right  iliac  fossa.  I  have  upon  several  occasions 
seen  cases  diagnosed  as  appendicitis  in  which  the  course  of  events 
clearly  demonstrated  that  the  intra-thoracic  condition  present  was 
entirely  responsible  for  the  symptoms. 

The  treatment  of  appendicitis  in  children  is  precisely  that  in 
adults. 

The  prognosis  is  essentially  identical  with  the  prognosis  in  adults, 
possibly  somewhat  more  favorable. 


TYPHOID  APPENDICITIS. 

Typhoid  appendicitis  includes  a  number  of  lesions.  It  may  be 
considered  as  meaning  one  of  three  things. 

(a)  True  typhoidal  appendicitis,  i.  e.,  one  due  to  the  bacillus 
typhosus  occurring  during  the  course  of  typhoid  fever. 

(b)  Intercurrent  appendicitis  during  an  attack  of  typhoid  fever. 

(c)  Appendicitis  due  to  the  bacillus  typhosus  without  other 
typhoid  lesions. 

There  can  be  no  doubt  that  during  an  attack  of  enteric  fever, 
involving  as  it  does  the  lymphoid  structures  of  the  lov^er  ileum  and 
the  caecum,  there  is  often  to  be  found  a  corresponding  infiltration 
of  the  lymphoid  tissue  in  the  appendix.  Hopfenhausen  found  in  a 
study  of  thirty  persons  who  died  of  typhoid  fever,  that  the  appendix 
was  involved  in  eighteen,  and  in  four  of  these  the  appendix  was  held 
directly  responsible  for  the  death  of  the  patient.  It  is  questionable 
whether  every  case  of  involvement  of  the  lymph  follicles  of  the 
appendix  during  typhoid  fever  is  to  be  considered  as  of  specifically 
typhoidal  origin.  Perrone  in  a  consideration  of  appendicitis 
during  typhoid  fever  emphasizes  the  fact  that  while  we  may  have  a 
true  lymph-follicle  affection  of  the  appendix  in  the  course  of  the 
disease  that  the  typhoid  infection  may  act  merely  as  a  predisposing 
but  not  actually  causative  factor.  To  this  second  form  of  lymph- 
follicle  involvement  he  gives  the  term  "paratyphoid  of  Dieulafoy," 
the  latter  surgeon  having  been  one  of  the  first  to  make  a  careful 
study  of  the  subject.  The  term  in  English  is  unfortunate  and  should 
not  be  used,  as  "paratyphoid"  is  commonly  applied  to  infections 
of  the  intestinal  lymph  follicles  caused  by  organisms  cognate  with, 
but  in  some  ways  differing  from,  the  bacillus  of  Eberth. 

Perrone  states  that  the  second  form  of  lymph-follicle  involvement 
is  quite  common  but  generally  unrecognized.  This  is  certain,  for 
as  we  have  not  only  during  typhoid  fever  but  in  every  enteritis  and 
colitis  some  infection  of  the  appendiceal  area,  slight  tenderness  on 
deep  pressure  in  this  region  will  not  arouse  particular  attention. 

20I 


202  Appendicitis 

The  second  form  of  typhoid  appendicitis  is  a  true  intercurrent 
appendiceal  inflammation  encountered  during  an  attack  of  enteric 
fever.  This  has  been  noted  in  many  instances.  Perhaps  in  a 
majority  of  cases  this  may  find  a  predisposing  cause  in  the  secondary 
lymph-follicle  inflammation  described  by  Perrone.  There  is  no 
especial  immunity  to  appendicitis  conferred  upon  the  patient  by 
pre-existing  typhoid  fever,  so  that  even  were  there  no  predisposing 
lymphoid  congestion,  we  should  expect  to  find  in  a  certain  number 
of  cases  of  typhoid  fever  the  occurrence  of  an  appendicitis. 

Clinically  it  would  be  entirely  impossible  to  distinguish  a  marked 
typhoid  appendicitis  during  enteric  fever  from  the  intercurrent 
form,  and  even  at  operation  they  may  show  points  of  similarity. 
It  would  be  possible  in  a  certain  number  of  cases  to  determine 
by  bacteriological  and  histological  examination  whether  the  condi- 
tion were  a  part  of  the  disease  or  intercurrent,  but  the  difference 
has  but  little  of  practical  interest  in  so  far  as  it  might  affect  clinical 
diagnosis  or  surgical  treatment. 

L.  J.  Hammond  has  called  attention  to  the  relation  of  the  vermi- 
form appendix  to  perforation  in  typhoid  fever.  He  quotes  the 
statistics  of  several  investigators.  Gushing  found  the  lesion  in 
the  appendix  in  9.6  per  cent,  of  his  cases  of  typhoid  perforation; 
Fitz  had  3  per  cent,  in  a  series  of  167  cases  and  Hopfenhausen  had 
7  per  cent,  in  a  series  of  108  cases.  Finney  gives  5  per  cent,  as  the 
frequency  with  which  the  seat  of  the  perforation  is  found  to  be  in 
the  appendix.  Hammond  attaches  additional  importance  to  the 
condition  of  the  appendix  because  he  believes  that  a  considerable 
number  of  perforations  low  in  the  caecum  and  in  the  ascending  colon 
may  be  traced  to  previous  disease  of  the  appendix.  That  is  to  say 
the  appendix  often,  even  when  not  actually  diseased,  acts  as  a 
predisposing  cause  to  perforation  by  reason  of  the  adhesions  which 
have  formed  and  consequent  interference  with  the  function  of  the 
bowel. 

From  my  own  experience  I  would  consider  the  percentages  of 
perforation  of  the  appendix  in  a  series  of  typhoid  perforations  as 
somewhat  high.  I  have  not  found  appendiceal  perforation  during 
typhoid  to  be  other  than  a  rare  condition. 

In  addition  to  these  two  forms  of  appendiceal  involvement 
during  an  attack  of  typhoid  fever  there  is  a  form  in  which  the  typhoid 


Typhoid  Appendicitis  203 

affection  serves  to  produce  an  acute  exacerbation  of  an  already 
chronically  diseased  appendix.  In  other  words  we  really  have 
typhoid  occurring  in  the  course  of  chronic  appendicitis  and  causing 
the  latter  to  take  on  a  new  acute  form. 

C.  Leedham  Green  reports  a  case  of  atypical  typhoid  fever  arous- 
ing latent  appendicitis  in  which  there  was  a  clear  history  of  appen- 
diceal involvement.  Previously  stress  has  been  laid  upon  the 
importance  of  typhoid  fever  as  a  causative  factor  in  appendicitis 
in  later  years.  It  is  possible,  however,  that  in  many  of  the  patients 
in  whom  this  has  seemed  to  be  the  sequence  of  events  the  typhoid 
fever  acts  merely  as  the  stimulus  arousing  to  activity  a  pre-existing 
but  latent  appendiceal  lesion.  Especially  would  this  seem  probable 
in  view  of  the  frequency  with  which  patients  are  apt  to  overlook 
mild  symptoms  referable  to  subacute  or  chronic  appendicitis. 

The  third  great  group  of  cases  of  typhoid  appendicitis  is  that  in 
which  we  have  cases  of  appendicitis  due  to  the  bacillus  typhosus 
without  other  lesions  of  typhoid  fever.  These  patients  present  the 
clinical  signs  of  appendicitis  and  not  of  typhoid  fever.  I  have  had 
an  instance  of  this  condition.  John  B.  Roberts  reports  a  case  of 
perforating  typhoidal  appendicitis  in  a  boy  of  nine.  His  examina- 
tion showed  that  the  lymphoid  structures  of  the  appendix  were 
affected  just  as  the  lymphoid  structures  in  the  intestine.  W.  R. 
Stokes  and  A.  L.  Amick  report  a  case  of  typhoid  appendicitis  without 
other  intestinal  lesions.  The  attack  was  a  typical  one  of  acute 
appendicitis  and  after  operation  eventuated  in  recovery.  They 
conclude  that  the  infection  was  limited  to  the  appendix  because 
forty-eight  hours  after  the  appendectomy  the  patient's  temperature 
dropped  to  the  normal.  In  this  instance  the  bacillus  pyocyaneus 
was  found  in  conjunction  with  the  bacillus  typhosus. 

As  to  diagnosis,  the  several  groups  of  typhoid  appendicitis 
present  different  problems.  In  the  third  group,  that  in  which  the 
appendix  alone  is  involved,  we  have  the  simple  differentiation  be- 
tween acute  appendicitis  and  typhoid  fever — usually  not  a  distinction 
very  difficult  to  determine.  This  will  be  fully  dealt  with  in  the 
chapter  upon  Differential  Diagnosis. 

The  diagnosis  of  those  cases  in  which  we  are  led  to  suspect 
the  presence  of  acute  appendicitis  during  an  attack  of  typhoid 
fever  is  a  matter  of   far  greater  difficulty.     We  may  take  it  for 


204  Appendicitis 

granted  that  it  will  be  impossible  clinically  to  differentiate  those 
cases  which  are  due  to  the  bacillus  typhosus  and  those  in  which 
we  have  an  intercurrent  appendiceal  involvement  due  to  other 
organisms. 

The  classical  symptoms  of  acute  appendicitis  at  all  times 
are  pain,  tenderness  and  rigidity.  Should  the  onset  be  quite  acute 
the  pain  is  often  followed,  but  never  preceded,  by  vomiting.  In  a 
patient  suffering  from  typhoid  we  often  encounter  sufl&cient  abdom- 
inal rigidity  and  tympanites  to  render  an  exacerbation  of  these 
symptoms  difficult  to  determine.  In  practically  all  cases  of  enteric 
fever  also  there  is  a  certain  amount  of  tenderness  upon  deep  pressure 
in  the  right  iliac  fossa — this  being  the  location  of  the  highly  inflamed 
lower  ileum.  In  highly  neurotic  or  susceptible  individuals  exami- 
nation hastily  carried  out  might  lead  to  a  suspicion  of  appendicitis. 
The  pain  of  appendicitis  occurring  during  typhoid  fever,  particularly 
if  it  be  of  the  true  enteric  type,  is  apt  to  be  more  insidious  and 
gradually  increasing  in  intensity,  accompanied  by  increasing 
tenderness  and  localized  rigidity.  I  have,  however,  seen  on  several 
occasions  appendicitis  during  typhoid  coming  on  with  all  the 
classical  symptoms  strongly  marked.  The  blood  count  may  be  of 
some  value  in  determining  the  presence  or  absence  of  intercurrent 
appendiceal  infection,  especially  if  it  be  caused  by  one  of  the  pus- 
forming  organisms.  The  normal  leucopenia  of  typhoid  may  give 
way  to  a  more  or  less  marked  leucocytosis.  It  is  well  to  bear  in 
mind,  however,  that  in  typhoid  the  leucopenia  is  not  at  all  times 
present,  and  that  we  may  have  as  a  result  of  secondary  infections 
of  obscure  location  a  more  or  less  constant  leucocytosis.  Again, 
as  has  been  pointed  out  in  the  chapter  on  the  blood  count  in  appen- 
dicitis, the  blood  count  as  regards  the  presence  or  absence  of  leuco- 
cytosis is  a  most  uncertain  portion  of  the  clinical  picture  of  the 
disease  and  not  worthy  of  great  reliance. 

There  are  several  conditions  occurring  during  typhoid  fever 
with  which  appendicitis  may  be  confused. 

As  regards  differential  diagnosis,  it  is  above  all  things  im- 
portant for  the  abdominal  surgeon  to  familiarize  himself  with 
the  clinical  aspects  of  typhoid  fever.  An  unwary  surgeon  would 
many  a  time  open  up  a  patient's  belly  if  the  physician  were  not 
at  hand  to  exclaim  that  pain  in  this  case  was  an  everyday  occur- 


Typhoid  Appendicitis  205 

rence;  that  that  patient  constantly  stiffened  his  abdominal  muscles 
whenever  any  one  came  near  him;  and  that  time  and  again  the  num- 
ber of  leucocytes  rose  to  twelve  and  even  fifteen  thousand  in  typhoid 
fever  without  the  patient  being  apparently  the  worse. 

Fortunately  it  is  in  the  earliest  stages  of  typhoid  fever  that  the 
diagnosis  is  most  difficult,  at  a  period  of  this  disease  when  a  simple 
laparotomy  is  well  borne,  and  hence  a  mistaken  diagnosis  is  not  so 
serious  as  it  becomes  during  the  third  or  fourth  week  of  the  fever. 
But  even  in  the  early  stages  a  correct  diagnosis  is  not  by  any  means 
impossible.  Pain,  tenderness  and  rigidity,  the  classical  symptoms 
of  appendicitis,  may  all  be  present,  yet  if  a  history  of  malaise,  head- 
ache, epistaxis,  and  slight  diarrhoea  is  obtained,  the  case  is  most 
probably  one  of  typhoid  fever:  there  may  be  slight  medullary 
infiltration  of  the  appendicular  lymph  nodes  commencing,  but  it 
is  not  a  true  appendicitis.  The  fever  is  too  high  and  the  pulse  is 
too  slow.  The  tongue  will  often  decide  the  surgeon — ^in  typhoid 
the  typical,  furred  tongue  is  observed  sufficiently  early  to  warrant 
its  being  considered  a  valuable  sign.  Even  a  palpable  mass  may  be 
due  not  to  an  inflamed  appendix,  but  to  enlarged  mesenteric  glands. 
The  blood  count  is  relied  upon  to  a  very  large  extent  by  most  sur- 
geons as  a  differential  mark,  and  such  a  count,  should  be  made 
whenever  at  all  possible.  The  normal  leucopenia  of  typhoid 
fever  is  well  recognized,  and  it  is  probably  safe  to  say  that 
without  an  increase  in  the  number  of  the  white  blood  cells  appen- 
dicitis is  not  present,  unless  the  intoxication  be  overwhelming. 
This  is  a  matter  which  is  readily  determined,  as  a  rule,  by  the 
clinical  picture  which  the  patient  presents. 

It  has  recently  been  noted  by  Crile  that  in  a  number  of  cases  the 
onset  of  peritonitis  has  caused  a  marked  increase  in  the  blood  pres- 
sure.    This  sign  might  possibly  be  of  service  in  obscure  cases. 

From  intestinal  perforation,  when  this  condition  is  typical,  the 
diagnosis  should  not  be  difficult.  In  typhoid  perforation  this  pain 
is  usually  sharp,  severe,  of  sudden  onset  and  quickly  subsiding. 
The  pain  of  appendicitis,  is  usually  less  acute,  comes  on  more 
gradually,  is  apt  to  last  longer  and  to  be  colicky  in  character.  In 
appendicitis,  even  if  there  be  perforation,  the  shock  is  not  so  great 
as  in  perforations  of  other  parts  of  the  intestinal  tract;  the  pulse 
rate  does  not  change  so  suddenly  from  the  slow  beat  of  typhoid 


2o6  Appendicitis 

fever  to  the  rapid  pulse  characteristic  of  perforation;  there  is  very 
seldom  the  fall  of  temperature  which  is  not  infrequently  observed  in 
cases  of  perforation  of  the  bowel;  and  finally  the  course  of  the  case, 
where  it  is  simply  watched,  and  where  no  operative  interference 
is  undertaken,  is  not  so  alarmingly  rapid  to  a  fatal  termination. 

From  intestinal  hemorrhage,  which  is  as  a  rule  unaccompanied 
by  pain,  appendicitis  is  not  so  difficult  to  distinguish  as  it  is  from 
intestinal  perforation.  The  haemorrhage  usually  declares  its  pres- 
ence in  the  stools  in  the  course  of  an  hour  or  so;  and  previous  haemor- 
rhages in  the  same  patient  would  incline  us  to  favor  this  diagnosis 
rather  than  appendicitis. 

Thrombosis  of  the  iliac  or  femoral  veins  may  be  a  misleading 
factor,  and  may  even  give  rise  to  a  palpable  tumor  as  well  as  to 
resistance  in  the  right  iliac  region.  But  while  this  condition  presents 
some  of  the  signs  of  appendicitis,  it  has  others  which  are  not  char- 
acteristic of  that  disease,  such  as  soreness  along  the  trunks  of  the 
femoral  veins,  with  oedema  of  the  extremity  affected;  and  it  moreover 
lacks  some  features  of  appendicitis,  such  as  the  vomiting,  the  sudden 
pain,  and  the  intestinal  disturbance  so  common  in  that  disease. 

Affections  of  the  gall-bladder  during  the  course  of  typhoid  fever 
are  not  usually  difficult  to  distinguish  from  appendicitis.  The 
symptoms,  as  a  rule,  occur  in  the  upper  right  quadrant  of  the  ab- 
domen, where  a  well-defined  mass  may  frequently  be  felt.  A  history 
of  jaundice  with  previous  similar  attacks  may  possibly  be  elicited. 
In  any  event  delay  in  resort  to  operative  measures  during  the  height 
of  the  typhoid  fever  is  even  more  allowable  here  than  where  the 
appendix  is  affected. 

The  prognosis  of  appendicitis  during  typhoid  fever  is  a  matter 
of  much  uncertainty,  and  to  the  reproach  of  medicine  it  must  be 
confessed  that  it  is  little  influenced  by  treatment.  Yet  it  may 
certainly  be  considered  a  graver  affection  than  when  occurring  in 
an  otherwise  healthy  individual.  If  the  appendix  is  removed  before 
the  inflammation  has  advanced  beyond  its  first  stages,  the  result 
will  be  almost  invariably  favorable,  the  influence  of  such  an  opera- 
tion on  the  typhoid  affection  in  its  early  stages  being  practically  nil. 
The  inch  long  wound  can  be  sealed  with  collodion  over  the  sutures, 
and  the  bath  treatment  pursued  without  interruption.  If,  however, 
an  equally  simple  operation  is  undertaken  during  the  second  or 


Typhoid  Appendicitis  207 

third  week  of  the  fever,  it  alone  may  be  enough  to  determine  fatally 
an  affection  from  which,  without  such  interference,  recovery  would 
have  been  uneventful.  Still  more  serious  is  the  case  where  perfora- 
tion, gangrene,  or  suppuration  occurs  in  the  appendix,  especially 
during  the  height  of  the  fever,  or  in  one  whose  convalescence  is  not 
sufficiently  far  advanced.  Yet  even  such  lesions  of  the  appendix 
during  typhoid  fever  are  not  so  serious  as  perforations  of  the  ileum: 
eight  cases  where  only  the  appendix  was  perforated,  collected  by 
Harte  and  Ashhurst,  gave  a  mortality  after  operation  of  50  per  cent.; 
while  the  mortality  they  give  for  intestinal  perforation  in  general, 
when  treated  by  laparotomy,  is  over  74  per  cent. 

I  have  had  under  my  care  a  case  of  appendicitis  during  typhoid 
fever,  where  the  attending  physician  was  urgent  for  immediate 
operation  on  at  least  two  occasions;  but  as  I  was  unable  to  say  that 
an  operation  would  not  subject  the  patient  to  greater  risk  than  would 
waiting  under  constant  surgical  supervision,  and  as  I  could  detect 
no  evidence  of  pus  formation,  I  was  unwiUing  to  operate;  and  in 
each  instance,  as  it  happened,  the  patient  shortly  had  a  fearful 
intestinal  haemorrhage,  and  very  nearly  lost  his  life;  and  I  could 
not  help  feeling  that  with  the  added  shock  of  a  laparotomy,  however 
slight,  he  would  have  been  unable  to  recover.  Some  weeks  after 
complete  re-establishment  of  his  health,  I  removed  with  perfect 
success  a  chronically  inflamed  appendix  from  among  numerous 
adhesions. 

Of  importance  in  this  connection  is  the  condition  mentioned  by 
Perrone,  i.  e.,  typhoid  peritonitis  by  propagation  as  the  result  of 
undiagnosed  appendicitis  without  perforation  of  the  latter  viscus. 
Typhoid  peritonitis  without  perforation  is  occasionally  found,  but 
is  a  very  rare  condition.  We  often  see  a  mild  peritoneal  irritation 
during  typhoid  fever,  but  rarely  a  frank  peritonitis  unless  there  be  a 
perforation.  If  in  these  cases  the  appendix  is  not  perforated  it 
appears  more  logical  to  attribute  the  non-perforative  peritonitis 
to  penetration  of  the  bacteria  through  the  large  intestinal  area 
involved,  rather  than  through  the  comparatively  small  area  furnished 
by  the  walls  of  the  appendix. 

The  treatment  of  typhoid  appendicitis  must  vary  with  the 
grade  of  appendicitis  and  the  stage  of  the  fever  during  which  it 
occurs,  and  its  course  during  a  short  period  of  observation. 


2o8  Appendicitis 

A  frank  acute  appendicitis  during  the  early  weeks  of  typhoid 
fever  should  be  operated  upon  if  it  be  recognized  in  its  earliest 
stages,  and  the  operation  will  probably  have  no  bad  effect  upon  the 
further  course  of  the  disease.  The  mild  appendiceal  irritation,  if 
it  may  be  so  called,  often  encountered  in  the  first  ten  days  of  an 
enteric  fever  will  practically  always  subside  without  operation 
just  as  a  corresponding  typhoid  cholecystitis  will  under  similar 
conditions. 

When  the  patient  has  reached  the  height  of  the  fever  any  abdom- 
inal section  necessitating  anaesthesia  unfavorably  influences  the 
subsequent  course  of  the  disease.  It  is  wise,  therefore,  even  when  a 
diagnosis  of  appendicitis  can  be  made  to  await  the  evidence  that  it 
will  not  spontaneously  subside,  rather  than  to  operate  upon  all 
grades  of  appendiceal  inflammation  at  once  and  during  all  stages  of 
typhoid  fever.  If  true  acute  appendicitis  be  present  we  should 
operate  in  case  the  progress  of  the  disease  indicates  the  imminence 
of  perforation  or  further  infection  of  the  peri-appendiceal  area,  but 
should  not  tamper  with  cases  which  are  seen  to  progress  favorably 
without  operation. 


DIAGNOSIS. 

The  diagnosis  of  acute  appendicitis  is  ordinarily  attended  by  few 
difficulties.  When  the  three  cardinal  symptoms  of  the  disease  are 
present — that  is,  sudden  onset  of  acute  abdominal  pain,  followed 
by  vomiting,  occurring  in  one  previously  well;  unilateral  rigidity 
of  the  right  lower  abdominal  wall;  tenderness  over  the  site  of  the 
appendix — the  diagnosis  of  acute  appendicitis  is  warranted  in  nearly 
every  case.  The  reasons  for  the  failure  of  the  attending  physician 
or  surgeon  to  make  the  correct  diagnosis  are  errors  in  theory 
and  in  practice.  The  most  important  error  in  theory  is  his  disbelief 
in  the  existence  or  at  least  in  the  great  frequency  of  appendicitis  as 
a  disease.  There  lurks  in  the  minds  of  a  great  many  men  a  persist- 
ing belief  in  a  primary  typhlitis,  whether  stercoral  or  idiopathic, 
and  some  physicians  even  at  the  present  day  seem  averse  to  the 
realization  of  the  fact  that  it  has  been  proved  over  and  over  again 
that  the  appendix  is  always  the  original  seat  of  trouble  in  acute 
inflammation  of  the  right  iliac  fossa.  The  picture  before  the  eyes 
of  these  gentlemen  is  that  of  a  caecum  loaded  with  stagnant  faeces, 
their  one  idea  is  to  empty  the  bowel  by  a  drastic  purge;  and  they 
cannot  be  convinced  that  purgation  from  now  until  doomsday  will 
not  check  in  the  slightest  degree  the  progress  of  the  inflammation 
in  the  appendix  vermiformis.  They  have  the  common  habit  of 
speaking  of  all  gastro-intestinal  disorders  attended  by  pain,  nausea 
and  vomiting,  as  "inflammation  of  the  bowels."  They  make  no 
attempt  to  localize  the  seat  of  this  inflammation,  and  are  prone  to 
consider  the  pathological  conditions  present  merely  an  "irritation," 
even  while  they  call  it  "inflammation." 

If  from  the  mental  horizon  of  such  individuals  as  these  the  caecum 
could  be  eliminated,  there  would  appear  looming  up  in  the  fore- 
ground in  the  position  of  prime  importance  that  source  and  fountain 
of  all  evil,  the  vermiform  appendix.  And  if  this  little  worm-like 
treacherous  structure  was  ever  in  mind,  the  greatest  error  of  all,  one 
which  I  may  almost  call  a  crime,  the  neglect  of  physical  examination, 
14  209 


2IO  Appendicitis 

would  be  absent.  Never  should  any  patient  who  presents  pain  in 
the  abdomen  go  unexamined. 

Failures  in  diagnosis,  however,  may  often  be  explained  by  the 
fact  that  the  initial  symptoms  were  insignificant,  were  lost  sight  of, 
or  were  obscured  by  the  injudicious  use  of  opium.  The  commence- 
ment of  an  attack  of  acute  appendicitis  mayveryclosely  simulate  acute 
indigestion,  in  that  there  occur  vomiting,  colicky  pains,  often  impli- 
cating the  entire  abdomen,  and  tenderness.  But  in  acute  appendicitis 
there  is  nearly  always  a  certain  sequence  of  symptoms — pain,  vomiting, 
tenderness — and  rigidity  of  the  rectus  muscle  is  nearly  universal. 
If  this  sequence  of  symptoms — (i)  pain;  (2)  vomiting;  (3)  tenderness 
— ^is  altered,  the  diagnosis  of  acute  appendicitis  may  well  be  considered 
doubtful;  and  where  acute  appendicitis  is  present  and  these  symptoms 
have  not  occurred  in  the  order  described  other  signs  are  generally 
present  which  render  the  diagnosis  certain.  Fever  nearly  invariably 
appears  later  than  the  three  symptoms  first  mentioned.  If  hyper- 
pyrexia occurs  first,  typhoid  fever  may  be  suspected,  or  pneumonia; 
if  vomiting  occurs  first,  acute  indigestion  or  scarlet  fever  may  be  the 
cause;  while  where  tenderness  precedes  the  other  symptoms  for 
some  hours  or  days,  pelvic  disease,  or  chronic  intestinal  ulceration 
are  to  be  considered.  These  points  have  recently  received  special 
study  by  Murphy,  and  to  his  masterly  exposition  of  the  subject  too 
much  credit  cannot  be  given. 

Not  only  is  the  above  sequence  of  symptoms  nearly  universal, 
but  each  of  the  symptoms  mentioned  is  different  in  acute  appendicitis 
from  what  it  is  in  other  diseases.  Thus  the  general  abdominal  pain 
which  is  usually  the  first  symptom,  soon  settles  to  the  right  iliac 
fossa,  which  fact  should  at  once  lead  to  the  supposition  of  more 
serious  trouble  than  simple  indigestion.  Although  the  pain  is 
usually  localized  to  the  right  iliac  fossa  it  is  not  always  so.  It  varies 
with  the  position  of  the  appendix.  But  the  important  point  is  that 
it  is  first,  almost  universally,  general,  and  then  becomes  localized; 
it  does  not  disappear.  As  already  noted  in  the  symptomatology, 
where  the  appendix  points  north  the  pain  may  be  referred  to  the 
lumbar  or  hepatic  region.  In  certain  cases  it  is  referred  exclusively 
to  the  left  side;  in  such  cases  the  appendix  usually  points  south  and 
occupies  the  pelvis,  but  it  may  point  east.  The  downward  and  pelvic 
positions  causing  pain  in  the  left  side  must  be  emphasized,  as  I 


Diagnosis  '  211 

have  seen  a  number  of  cases  in  which  the  attending  physicians,  who 
were  familiar  with  the  general  symptoms  of  acute  appendicitis,  were 
totally  misled  by  the  reference  of  the  pain  to  the  left  side.  The  cita- 
tion of  one  case,  that  of  the  son  of  a  physician,  will  serve  to  illus- 
trate the  importance  of  pain  referred  to  the  left  side  as  indicative  of 
the  pelvic  position  of  the  appendix. 

Master  A.,  shortly  after  a  meal  of  indigestible  food,  was  suddenly  seized 
with  acute  abdominal  pain,  vomiting  and  rigidity  of  the  right  lower  abdominal 
wall.  Symptoms  of  acute  peritonitis  developed  on  the  third  day,  whereupon 
the  father  consulted  me,  stating  that  he  would  have  regarded  the  case  as  one 
of  appendicitis  had  the  pain  not  been  referred  to  the  left  side.  I  told  him  that 
in  my  opinion  the  disease  was  appendicitis,  and  that  immediate  operation  was 
demanded.  Two  days  later,  I  was  hastily  summoned  to  see  the  boy,  whom  I 
found  suffering  from  a  diffuse  peritonitis  of  an  active  type  He  had  a  pulse-rate 
of  130  a  minute,  a  "leaky"  skin,  was  constantly  retching,  and  had  obstinate 
constipation.  I  declined  to  interfere  except  to  advise  discontinuance  of  opium 
and  all  its  preparations.  Apparent  recovery  followed.  I  then  advised  opera- 
tion to  prevent  recurrence,  but  the  father  declined  to  have  his  son  operated  upon 
when  in  apparent  good  health.  Within  ten  days  a  second  attack  occurred. 
I  was  again  summoned,  but,  being  absent  from  home,  other  counsel  was  sought, 
and  operation  again  deferred.  Apparent  recovery  again  ensued.  Again  I  was 
consulted  and  again  advised  operation,  to  which  objection  was  no  longer  made. 
At  operation  the  appendix,  the  tip  of  which  contained  a  collection  of  pus,  and 
the  whole  of  which  was  surrounded  by  a  circumscribed  abscess,  was  found 
occupying  the  pelvis,  adherent  to  its  floor  and  to  the  right  side  of  the  rectum. 
The  appendix  was  removed  and  an  uneventful  recovery  followed. 

It  is  in  this  class  of  cases  where  the  appendix  is  in  the  pelvis,  and 
the  pain  is  referred  to  the  left  side,  that  rectal  and  vesical  symptoms 
may  be  complained  of.  Hence  the  presence  of  tenesmus,  or  of 
vesical  irritability,  frequent  urination,  or  retention  of  urine,  occurring 
in  cases  where  other  symptoms  indicate  acute  appendicitis,  should 
make  us  suspect  a  pelvic  position  of  the  appendix. 

The  pain  of  acute  appendicitis  is  further  characterized  by  its  ten- 
dency to  subside  gradually  in  the  course  of  four  or  five  hours.  If  the 
pain  subsides  suddenly  at  any  period  of  the  disease,  it  is  usually 
an  indication  of  gangrene  or  perforation  and  operation  should  be 
undertaken  without  delay.  When  the  pain  has  subsided  in  the 
normal  manner,  that  is,  gradually,  it  may  not  recur  in  a  few  cases. 
In  these  the  appendicular  colic  has  probably  been  terminated  by 
the  lumen  of  the  appendix  freeing  itself  of  obstruction.     But  in 


212  Appendicitis 

the  great  majority  of  cases  the  pain  recurs  at  intervals  of  a  few 
hours,  and  with  gradually  increasing  intensity,  becoming  finally, 
after  twenty-four  to  thirty-six  hours,  nearly  constant,  and  not  of 
a  colicky  nature. 

The  vomiting,  which  is  nearly  always  the  second  symptom,  is 
a  reflex  act,  and  is  usually  not  repeated,  unless  the  stomach  is  full, 
and  has  not  been  emptied  at  the  first  effort.  When  nausea  and  vom- 
iting recur  at  a  later  period,  they  are  an  evidence  of  progressing  peri- 
appendicular inflammation,  and,  like  the  secondary  pain,  are  of 
bad  prognostic  import.  The  first  reflex  vomiting  is  also  seen,  as 
remarked  by  Murphy,  where  other  hollow  organs  attempt  to  free 
themselves  of  impacted  calculi,  as  in  the  case  of  gall-stones  and 
nephritic  colic,  or  where  a  vesical  calculus  becomes  impacted  in  the 
neck  of  the  bladder;  while  the  secondary  vomiting  is  comparable  to 
that  produced  by  perforation  of  the  stomach,  intestine  or  Fallopian 
tube. 

The  tenderness  of  acute  appendicitis  is  of  much  the  same  general 
character  as  the  pain.  It  is  at  first  diffuse,  and  later  becomes  local- 
ized to  the  right  iliac  fossa,  and  the  point  of  greatest  tenderness, 
usually  McBurney's  point,  generally  corresponds  with  the  position 
of  the  inflamed  appendix.  This  localized  tenderness  is  one  of  the 
most  constant  and  valuable  signs  of  appendicitis.  Both  superficial 
and  deep  tenderness  are  present  at  this  stage.  The  superficial 
tenderness  is  due  to  reflex  irritation  of  the  cutaneous  nerves,  as  ex- 
plained in  the  section  on  Anatomy,  and  is  best  elicited  by  gently 
stroking  or  pinching  the  skin,  beginning  in  unaffected  areas,  and 
gradually  outlining  the  area  of  cutaneous  hyperassthesia.  This 
superficial  tenderness  is  generally  present  from  the  first,  but  the 
deep  tenderness  does  not  develop  until  the  stage  of  appendicular 
colic  is  passed.  As  a  rule  the  superficial  sensitiveness  is  confined 
to  the  right  iliac  region  in  the  shape  of  a  triangle,  extending  nearly  to 
the  median  line  in  front,  almost  to  Poupart's  ligament  below,  and 
having  its  apex  above  the  anterior  superior  iliac  spine  in  the  anterior 
axillary  line;  it  may,  on  the  other  hand,  extend  back  to  the  spine  in  the 
form  of  a  band,  or  be  confined  to  a  small  circular  area  at  McBurney's 
point.  I  do  not  think  it  is  so  important  as  some  authors  would  have 
us  believe,  nor  of  nearly  such  diagnostic  value  as  the  deep  tenderness 
due   to   the   inflamed   appendix. 


Diagnosis  213 

In  some  cases  of  suspected  acute  appendicitis  palpation  of  the  ab- 
dominal wall  will  reveal  only  moderate  tenderness;  the  point  of  most 
marked  tenderness  being  detected  by  vaginal  or  rectal  examination. 
In  acute  cases  it  is  usually  not  at  all  difficult  to  elicit  tenderness. 
When  asked  to  locate  the  point  of  greatest  tenderness,  the  patient 
will  himself  almost  invariably  direct  attention  to  the  site  of  the  appen- 
dix. Palpation  over  this  region  besides  detecting  marked  tender- 
ness, may  provoke  wave-like  exacerbations  of  pain.  In  chronic 
cases  it  is  more  difficult  to  locate  tenderness,  but  deep  pressure  is 
nearly  always  successful,  and  may  reveal  a  thickened  organ.  Assist- 
ance may  be  had  by  comparing  the  conditions  upon  the  opposite 
side  of  the  body. 

There  is  usually  a  close  relationship  between  the  degree  of 
tenderness  and  the  progress  of  the  disease.  As  a  rule,  increase  of 
tenderness  denotes  progression  of  the  inflammatory  lesions,  while 
decrease  of  tenderness  occurring  without  the  administration  of 
anodynes  generally  indicates  subsidence  of  the  inflammation. 
Unlike  pain,  tenderness  as  a  rule  does  not  disappear  at  the  onset  of 
gangrene  or  perforation  of  the  appendix,  but  usually  becomes  more 
marked.  If  pus  is  present  the  pain  is  usually  exquisite,  especially  if 
the  pus  is  under  tension.  Palpation  after  the  first  twenty-four 
hours  of  an  acute  attack  should  be  extremely  cautious  and  gentle,  as 
a  small  abscess  not  easily  detected  may  be  unwittingly  ruptured  with 
disastrous  consequences.  Where  the  abscess  is  larger,  it  is  both 
more  evident,  and  the  tenderness  is  less,  as  septic  absorption  may 
have  progressed  to  such  an  extent  that  paralysis  of  the  nerve  fila- 
ments has  occurred.  Under  such  circumstances,  however,  the  other 
signs  of  acute  appendicitis  are  unequivocal.  Tenderness  is  marked 
in  any  peri-appendicular  suppurative  peritonitis,  whether  it  owe  its 
origin  lo  ulceration,  with  or  without  perforation,  to  gangrene,  or 
other  cause.     In  general  peritonitis  the  tenderness  is  widespread. 

The  rigidity  of  appendicitis  is  also  a  reflex  phenomenon,  due 
to  the  stimulation  of  motor  nerve  filaments,  as  explained  in  the 
section  on  Anatomy.  It  is  a  rigidity  that  is  not  produced  by  palpa- 
tion, but  which  exists  before  palpation  is  attempted;  and  is  hence 
evident  upon  very  gentle  pressure.  In  the  majority  of  cases  it  is 
confined  to  the  right  side,  and  most  frequently  to  the  lower  half  of 
the  rectus  muscle  of  that  side.     It  is  well  known  that  the  gall-bladder 


214  Appendicitis 

when  distended  is  similarly  protected  by  its  overlying  muscles,  and 
inflamed  joints  are  held  rigid  by  their  enveloping  muscles,  for  the 
same  reason,  as  long  ago  pointed  out  by  Hilton.  When  the  pain  and 
tenderness  are  on  the  left  side,  the  rigidity  is  more  pronounced 
on  that  side.  If  the  diseased  appendix  and  a  consequent  appen- 
dicular abscess  occupy  the  pelvis,  the  abdominal  rigidity  will  be 
bilateral,  as  is  illustrated  by  the  following  case: 

Miss ,  about  two  weeks  prior  to  my  first  visit,  was  suddenly  attacked 

by  what  at  first  seemed  to  be  acute  indigestion.  It  did  not  yield  to  ordinary 
medication.  In  view  of  the  fact  that  the  spleen  was  enlarged,  that  spots  were 
present  upon  the  abdomen,  and  because  the  temperature  was  irregular,  a 
provisional  diagnosis  of  typhoid  fever  had  been  made.  On  the  other  hand,  the 
suddenness  of  the  onset  of  the  affection,  the  acute  abdominal  pain,  the  decided 
bilateral  rigidity  of  the  lower  abdominal  wall,  the  irregular  temperature,  the 
great  pain  produced  by  rectal  and  vaginal  examination,  and  the  characteristic 
fullness  of  the  pelvis  rather  indicated  appendicitis  with  a  large  collection  of 
pus  in  the  pelvis.  I  advised  immediate  operation,  but  adverse  opinion  of  other 
counsel  caused  postponement  for  two  days.  Operation  disclosed  a  large  collec- 
tion of  malodorous  pus,  and  the  appendix,  which  was  perforated,  occupying 
the  pelvis.  The  abscess  was  evacuated,  the  appendix  removed,  and  an  un- 
eventful recovery  ensued. 

This  muscular  contraction  is  at  times  confined  to  certain  fibres 
of  the  flat  muscles  of  the  abdomen,  for  reasons  discussed  in  the  sec- 
tion on  Anatomy.  Where  this  is  the  case  a  hasty  examination  may 
lead  the  surgeon  into  the  error  of  thinking  that  the  diseased  appendix 
is  superficial,  and  that  he  feels  it  just  beneath  his  fingers;  on  opening 
the  abdomen  he  will  then  be  surprised  to  find  it  several  inches 
distant  from  the  anterior  abdominal  wall,  perhaps  even  posterior  to 
the  caecum.  In  palpating  for  a  chronically  inflamed  appendix  other 
structures  may  also  be  mistaken  for  it;  among  these  are  the  outer 
border  of  the  rectus  muscle,  the  semilunar  aponeurosis,  the  inner 
border  of  the  internal  oblique  and  transversalis  muscle,  and  the 
anterior  crural  nerve  coursing  along  the  outer  border  of  the  psoas 
muscle. 

Elevation  of  temperature  is  present  in  the  early  stages  of 
acute  appendicitis  with  remarkable  uniformity.  Murphy  says  he 
would  not  operate  upon  a  case  where  he.  was  convinced  that  there 
had  been  no  fever  at  any  time.  But  the  fever  is  neither  the  first 
symptom  nor  is  it  marked.     Frequently  it  never  is  as  high  as  ioo°  F. 


Diagnosis  _  215 

It  rarely  appears  for  several  hours  after  the  onset  of  the  attack. 
Its  sudden  disappearance  is  significant  of  gangrene  or  perforation. 
Its  persistence  and  increase  is  usually  caused  by  peritoneal  involve- 
ment without  perforation.  As  pointed  out  by  Murphy,  elevation 
of  temperature  is  indicative  of  septic  absorption;  when  gangrene 
occurs  or  when  an  abscess  ruptures,  absorption  is  temporarily 
stopped,  in  the  first  instance  by  destruction  of  the  absorbing  surface, 
in  the  second  instance  by  decrease  of  tension.  A  secondary  eleva- 
tion of  the  temperature  indicates  involvement  of  a  new  tissue. 
A  careful  consideration  of  the  nature  and  cause  of  the  local 
distention  is  sometimes  demanded.  This  fullness,  as  has  already 
been  stated,  may  be  due  to  peri-appendicular  peritonitis  and  to 
inflammatory  lesions — serous  and  cellular  infiltration — of  the 
abdominal  wall.  In  certain  cases  the  oedema  of  the  abdominal  wall, 
associated  with  symptoms  of  another  disease,  may  lead  to  the  false 
impression  that  the  affection  is  not  appendicitis,  as  is  illustrated  by 
the  following  instance: 

Miss  H.  became  ill  ten  days  prior  to  my  examination.  She  had  presented 
the  usual  manifestations  of  acute  appendicitis,  but  owing  to  slight  jaundice 
and  decided  oedema  of  the  tissues  overlying  the  hepatic  region  and  the  lower 
right  chest,  there  was  some  doubt  in  the  mind  of  the  attending  physician  as  to 
the  location  of  the  inflammatory  process.  Upon  pressure  there  was  more  pain 
over  the  oedematous  area  than  over  the  usual  site  of  the  appendix.  From  a 
review  of  the  symptoms  of  the  patient  from  the  onset  of  the  attack,  however,  I 
concluded  that  the  case  was  one  of  suppurative  appendicitis,  and  that  the  organ 
pointed  north  and  was  located  behind  the  caecum.  Operation  confirmed  the 
correctness  of  these  views.  The  appendix,  gangrenous  and  separated  from  the 
caecum,  was  post-cscal,  and  surrounded  by  a  collection  of  pus  which  extended 
behind  the  liver  and  inward  to  the  vertebral  column.     Recovery  ensued. 

While  the  local  swelling  is  frequently  due  to  an  abscess,  cases 
are  seen  w^here  tympanitic  distention  of  the  caecum  or  intestines 
causes  the  whole  right  iliac  fossa  to  bulge;  and  where  an  abscess 
is  absent  or  very  small,  a  palpable  tumor  is  often  formed  by  a 
mass  of  infiltrated  omentum,  coiled  around  the  inflamed  appendix; 
and,  as  previously  mentioned,  the  band-like  contraction  of  some 
fibres  of  the  rectus  muscle  may  be  mistaken  for  the  appendix. 

Peri-appendicular  suppuration  is  thus  to  be  suspected  if,  after 
the  initial  symptoms  of  acute  appendicitis  have  been  observed,  the 
pain,  temperature,  but  especially  the  tenderness  persist,  and  when  a 


2i6  Appendicitis 

palpable  tumor  is  present.  Gangrene  without  suppuration  or 
perforation  is  indicated  by  sudden  cessation  of  the  pain  previously 
localized  in  the  region  of  the  appendix,  fall  of  temperature,  increased 
pulse-rate,  anxious  facial  expression,  and  more  or  less  relaxation  of  the 
skin,  perhaps  by  perspiration.  Rigidity  often  disappears  when  gan- 
grene occurs,  but  usually  persists  when  perforative  peritonitis 
develops. 

Leucocytosis  is  of  value  as  a  confirmatory  symptom.  If 
the  patient  reacts  well  to  the  infection,  the  white  blood  count  will  be 
high.  If  on  the  other  hand  the  system  is  overwhelmed  by  the 
infection  the  number  of  leucocytes  may  not  be  increased  from  the 
normal. 

Serum  Diagnosis. — Acting  upon  the  assumption  that  the  bac- 
terium coli  commune  is  the  predominant  factor  in  the  bacterial  origin 
of  most  cases  of  acute  appendicitis,  and  that  the  general  symptoms 
of  the  disease  are,  at  least  in  great  part,  due  to  the  toxin  of  this 
bacterium,  some  investigations  bearing  upon  the  applicability  of 
the  Widal  test  with  this  bacterium  were  undertaken  in  the  Patho- 
logical Institute  of  the  German  Hospital.  It  was  hoped  that  this 
test  might  prove  of  some  value  in  the  diagnosis  of  the  disease,  more 
particularly  in  obscure  cases,  or  that  it  might  furnish  a  clue  to  the 
identity  of  the  causative  bacteria  or  to  the  severity  of  the  infection 
in  individual  cases.     No  definite  results,  however,  were  obtained. 

SUMMARY. 

In  the  diagnosis  the  three  cardinal  symptoms  are  most  im- 
portant: 

1.  Sudden  acute  abdominal  pain  in  one  previously  well. 

2.  Unilateral  rigidity  of  the  lower  abdominal  wall. 

3.  Tenderness  over  the  site  of  the  appendix. 

The  order  of  the  symptoms — (i)  pain;  (2)  vomiting;  (3)  tender- 
ness— is  very  characteristic. 

The  clinical  course  of  each  symptom  is  characteristic.  The  pain 
is  first  diffuse,  and  later  settles  in  the  right  iliac  fossa.  The  vomiting 
is  usually  not  repeated.  The  tenderness  is  general  at  first,  but  is 
soon  localized  to  the  region  of  the  appendix.  Rectal  and  vaginal 
examinations  are  always  valuable,  but  should  never  be  neglected 


Diagnosis  217 

when  abdominal  tenderness  is  not  marked  or  when  confusion  with 
tubo-ovarian  disease  is  possible.     The  fever  does  not  usually  appear 
until  after  the  lapse  of  some  hours;  next  to  never  is  it  the  first  symp- 
tom.    It  is  rarely  high  at  first. 
Tenderness  is  increased  in: 

1.  Pus  formation. 

2.  Gangrene  of  the  appendix. 

3.  Perforation  of  the  appendix. 
Tenderness  is  decreased: 

1.  Late  in  suppurative  cases  when    sufficient    toxins    have 
been  absorbed  to  paralyze  the  peripheral  nerve  filaments. 

2.  Upon   the   subsidence   of   the   disease. 

Abrupt  cessation  of  pain  may  indicate  gangrene  of  the  appendix. 

Pain  and  tenderness  on  the  left  side  indicate  that  the  appendix 
points  south  (rarely  east)  and  occupies  the  pelvis.  In  these  cases 
vesical  symptoms  are  common. 

Pain  on  the  left  side  with  tenderness  over  the  pubes  indicates 
that  the  appendix  points  south  and  that  the  tip  of  the  organ  alone 
is  involved,  or  that  it  is  the  seat  of  the  most  intense  inflammation. 

Pain  over  the  hepatic  or  the  right  renal  region,  with  tenderness 
over  the  course  of  the  ascending  colon,  indicates  that  the  appendix 
is  either  post-colic,  or  post-colic  and  post-caecal,  and  that  it  points 
north. 

Fullness  appears  late — after  the  development  of  an  inflammatory 
mass  or  the  occurrence  of  suppurative  peritonitis. 

Excrutiating  tenderness  is  the  most  reliable  sign  of  pus.  A  high 
leucocytosis  with  high  polynuclear  count  is  confirmatory. 

Distention : 

1.  Localized — is  due  to  localized  peritonitis. 

2.  General — is  due  to: 

(a)  Constipation. 

(b)  Administration  of  opium. 

(c)  Intestinal  paralysis,  the  result  of  sepsis. 

(d)  Mechanical  intestinal  obstruction. 

(e)  Diffusing  peritonitis. 

A  chill  denoting  pus  formation  is  rare. 

A  tumor  often  cannot  be  detected  on  account  of  the  tenderness 
and  rigidity.     When  adhesions  and  infiltration  are  present,  a  tumor 


2i8  Appendicitis 

is  usually  palpable.  Rectal  examination  is  often  successful  in 
determining  the  presence  of  a  tumor  or  fullness  when  abdominal 
palpation  is  entirely  negative. 

An  abscess  may  give  a  tympanitic  notion  light  percussion  due  to 
overlying  bowel  as  well  as  to  gas  contained  within  the  abscess. 

The  occurrence  of  a  chill  or  chills  early  in  the  disease  may  be 
indicative,  particularly  when  followed  by  high  temperature,  of 
gangrene;  also  may  be  due  to  nervousness.  Chills  late  in  the 
disease  when  followed  by  sweating  are  indicative  of  pus,  or  of  the 
development  of  pylephlebitis  and  hepatic  abscess. 


DIFFERENTIAL  DIAGNOSIS. 

While  in  the  majority  of  cases  the  recognition  of  appendicitis 
is  not  especially  difficult,  there  are,  nevertheless,  some  affections 
that  in  many  respects  so  closely  simulate  it  as  to  give  rise  to  per- 
plexities in  the  endeavor  to  discriminate  between  them.  Of  these 
the  most  important  are  various  disorders  of  the  gastro-intestinal 
tract,  particularly  typhoid  fever  and  other  morbid  conditions 
attended  by  ulceration  and  possible  perforation  of  the  bowel; 
disturbances  of  the  gall-bladder;  and,  especially  in  the  female, 
disease  of  the  genito-urinary  organs.  There  are,  in  addition, 
other  rarer  conditions  which  engender  difficulties  in  the  effort  to 
establish  a  differential  diagnosis,  and  which,  in  consequence, 
demand  consideration. 

Certain  of  these  conditions  are  acute  and  simulate  an  acute 
attack  of  appendicitis,  while  others  give  rise  to  symptoms  which 
lead  us  to  suspect  chronic  appendicitis  of  either  the  recurring  or 
latent  form. 

The  diseases  which  may  be  confounded  with  appendicitis  may 
be  conveniently  grouped  in  several  classes  based  upon  their  anatom- 
ical and  physiological  relations. 

ACUTE  GASTRO-INTESTINAL  INFLAMMATIONS. 

These  furnish  us  with  a  class  of  cases  which  give  close  resem- 
blance in  their  onset  to  acute  appendicitis.  The  more  common 
are  acute  gastritis,  acute  gastro-duodenal  catarrh,  acute  enteritis, 
and,  as  allied  conditions,  simple  intestinal  colic,  dysentery,  and 
colitis. 

In  all  of  these  inflammatory  conditions  mentioned  we  have, 
as  a  rule,  the  history  of  the  ingestion  of  some  food,  indigestible 
either  because  of  its  quantity  or  quality  (and  not  infrequently  after 
some  unusual  fatigue),  followed  shortly  by  nausea,  vomiting, 
flatulence,  colic,  and  in  those  forms  in  which  an  enteritis  is  present, 
'  by  diarrhoea. 

219 


220  Appendicitis 

The  history  of  the  case  will  in  every  instance  be  a  guide  of 
value  in  the  diagnosis,  though  too  much  stress  must  not  be  laid 
upon  it,  as  an  attack  of  appendicitis  may  follow  the  taking  of 
indigestible  food,  or  may  even  be  a  part  of  the  acute  gastro-enteritis 
itself. 

The  main  differential  features  in  each  of  these  conditions  are 
to  be  sought  in  a  careful  physical  examination.  We  have  seen 
that  in  appendicitis  there  is  a  history  of  pain  followed  by  vomiting, 
and  this  again  by  tenderness,  rigidity  and  fever.  The  initial  pain 
in  appendicitis  is  very  like  that  of  acute  gastritis  or  gastro-enteritis 
of  any  form,  but  in  any  of  these  conditions  the  nausea  or  vomiting 
usually  precede  the  pain.  Tenderness  is  less  constant  in  the  con- 
ditions noted,  and  in  none  of  them  is  it  localized  in  the  right  iliac 
fossa  even  when  exceptionally  it  is  present.  Indeed  it  is  a  well- 
known  fact  that  colic  under  these  conditions  is  alleviated  by  pressure, 
not  accentuated.  While  again,  rigidity  may  at  times  be  found  it  is 
of  a  more  general  nature  and  easily  overcome  by  persistent  pressure. 
Each  of  these  special  conditions  also  has  certain  features  which 
render  it  distinctive  in  symptomatology. 

Acute  gastritis  with  some  rise  of  temperature  might  resemble 
the  very  onset  of  appendicitis,  but  the  absence  of  tenderness  and 
rigidity  in  the  right  iliac  fossa  would  soon  render  the  diagnosis 
clear.  The  pain  is  never  localized  in  the  appendiceal  region  and 
as  a  rule  promptly  disappears  after  the  stomach  has  been  emptied 
by  vomiting.  Dietetic  indiscretions,  cardiac  and  hepatic  diseases 
are  marked  predisposing  factors. 

Acute  gastro-duodenal  catarrh  shows  itself  by  similar  symp- 
toms, at  times  associated  with  a  slight  icteric  coloring  of  the  skin 
and  sclera.  It  is  similarly  differentiated  from  appendicitis.  There 
may  be  some  rigidity,  but  when  the  latter  does  occur  it  is  bilateral, 
localized  to  the  upper  abdomen  and  quite  transient. 

Intestinal  colic  or  enteralgia  should  offer  no  real  difficulties 
in  diagnosis.     Appendicitis  may  be  excluded  by  examination. 

Acute  enteritis  in  the  adult  is  usually  not  difficult  to  recognize. 
In  children  it  may  be  very  hard  to  distinguish  from  appendicitis 
with  diarrhoea.  Here  the  history  is  not  to  be  obtained  and  the 
abdominal  examination  may  give  us  nothing  of  value.  Added  to 
this  is  the  fact  that  in  children  diarrhoea  is  far  more  common  in 


Differential  Diagnosis  221 


"ts 


appendicitis  than  in  adults.  A  painstaking  physical  examination 
will,  however,  if  repeated  and  made  when  the  voluntary  spasm  of 
the  abdominal  muscles  is  in  abeyance,  in  most  cases  give  us  some 
clue  to  the  real  nature  of  the  disease.  Rectal  examination  may  be  of 
value.  A  certain  distinction  between  appendicitis  and  enteritis  in 
the  young  may  be  entirely  impossible,  because  the  two  conditions 
may  merge.  The  presence  of  high  fever  would  favor  a  gastro- 
enteritis. McCosh  and  M.  Mathes  have  called  attention  to  the 
presence  of  marked  left-sided  pain  in  appendicitis  as  pointing  to  a 
concomitant  enteritis,  that  is,  a  colitis  with  retro-peritoneal  lymph- 
angitis. E.  Frank  has  recently  performed  a  series  of  autopsies  on 
children  who  had  died  of  acute  gastro-enteritis.  He  found  that 
the  appendix  was  invariably  greatly  involved,  and  especially  at 
its  tip.  It  is  easy  to  see  how,  under  these  circumstances,  enteritis 
might  give  rise  to  appendicitis,  and  that  only  repeated  physical 
examinations  would  show  us  when  the  borderline  had  been  passed. 
An  additional  point  of  similarity  has  lately  been  pointed  out  by 
Dun  who  has  found  that  tenesmus  is  quite  common  in  children 
who  have  appendicitis.     This  has  not  been  my  experience. 

Dysentery  and  colitis,  which  are  merely  special  forms  of 
enteritis,  may  in  equal  measure  simulate  appendicitis  and  in  the 
same  manner  be  distinguished  from  it  by  physical  examination. 

The  following  general  statement  may  be  made  of  the  differen- 
tial points  involved  in  the  group  of  acute  catarrhal  affections  of 
the  alimentary  tube. 

The  character,  the  mode  of  onset  and  the  exact  location  of  the 
pain  are  of  great  importance.  The  pain  of  the  gastro-enteritis 
group  begins  gradually  and  as  a  rule  is  preceded  by  malaise  and 
often  by  nausea.  The  pain  of  appendicitis  more  often  occurs 
suddenly  and  is  followed  by  nausea  and  vomiting.  The  pain  of 
gastro-enteritis  is  distinctly  colicky  with  intermissions,  that  of  appen- 
dicitis, while  it  may  be  colicky,  is  more  apt  to  be  sharp  and  constant. 
In  gastro-enteritis  the  pain  shifts  corresponding  to  the  segment  of 
the  intestine  in  which  the  painful  vermicular  contraction  is  going  on. 
In  appendicitis  it  is  constant  at  first  in  the  umbilical  or  epigastric 
region,  later  in  the  region  of  the  appendix.  Movement  aggravates 
the  pain  of  appendicitis  when  the  serous  surface  has  become  involved, 
as  it  usually  does  early  in  severe  attacks,  by  causing  inflamed  sur- 


22  2  Appendicitis 

faces  to  rub  against  each  other.  It  often  relieves  colic  by  relieving 
tension  upon  the  contracting  segment.  As  a  result  colicky  patients 
are  restless  and  toss  about  in  bed  while  those  who  have  peritoneal 
inflammation  are  quiet  and  do  not  like  to  change  their  position. 
Pressure  often  relieves  colic  while  it  aggravates  the  pain  of  peritonitis. 
Early  profuse  diarrhoea  is  common  in  enteritis,  rare  in  all  but  the 
pelvic  forms  of  appendicitis. 

In  enteritis  distention  and  borborygmi  are  early  features. 
Distention  in  appendicitis  comes  as  a  rule  only  after  the  development 
of  peritonitis. 

In  the  gastro-enteritis  group  true  localized  rigidity  and  tenderness 
are  absent.  The  rigidity  is  to  a  large  extent  voluntary  and  may 
be  overcome  by  patience.  In  appendicitis  the  muscular  guard  is 
unremitting.  Tenderness  in  gastro-enteritis  is  diffuse  and  often 
shifting,  in  appendicitis,  localized  and  constant. 

The  leucocyte  count  is  of  little  assistance  as  it  may  often  be  high 
in  enteritis. 

It  may  not  be  out  of  place  here  to  reiterate  the  warning  against 
the  use  of  opiates,  in  either  adults  or  children,  when  we  have  to  deal 
with  a  condition  which  in  its  onset  resembles  appendicitis  and  again 
to  insist  upon  a  proper  physical  examination,  even  when  we  are  most 
certain  that  there  is  simply  "colic"  or  "gastritis." 

Enterospasm. — ^I  do  not  consider  this  a  clinical  entity.  When 
symptoms  which  have  been  described  under  this  name  occur  they  re- 
semble those  of  chronic  appendicitis.  Hawkins,  who  has  especially 
studied  this  condition,  has  found  that  it  occurs  generally  in  neuras- 
thenics, is  always  associated  with  constipation,  and  that  the  pain 
occurs  generally  on  the  right  and  left  sides.  Upon  further  study  it 
will  be  found  to  be  either  a  manifestation  of  the  neurasthenia  which 
it  accompanies  or  of  an  underlying  chronic  entero-colitis.  A  knowl- 
edge of  its  occurrence,  however,  will  make  us  bear  the  possibility  in 
mind.  The  author  quoted  has  found  that  the  pain  in  these  instances 
is  unrelieved  by  appendectomy. 

Chronic  Intestinal  Stasis  may,  according  to  Lane,  cause  ab- 
dominal pain  in  varying  grades  and  locations.  This  may  be  such 
as  to  suggest  chronic  appendicitis  and  indeed  the  appendix  is  not 
infrequently  found  involved  in  this  condition.  Lane  believes  that 
chronic  appendicitis  is  often  secondary  to  chronic  intestinal  stasis 


Differential  Diagnosis  223 

being  produced  by  the  sagging  of  the  ileo-caecal  region  and  con- 
sequent production  of  kinks  and  interference  with  the  blood 
supply.  The  leading  symptom  in  these  cases  is  the  obstinate 
constipation  of  years  duration  and  the  patients  suffer  from  so- 
called  auto-intoxication,  the  chief  symptoms  of  which  have  been 
enumerated  by  Chappie  as  headache,  attacks  of  nausea,  loss  of 
appetite,  loss  of  weight,  markedly  cold  hands  and  feet,  mental 
apathy,  constant  foul  taste  in  the  mouth,  attacks  of  abdominal 
distention,  general  muscular  pains,  skin  staining  and,  in  the  female, 
breast  changes  in  the  way  of  chronic  mastitis  and  cystic  degenera- 
tion. 

DISTENTION  OF  THE  C/ECUM  WITH  ILEO-C^CAL  PAIN. 

This  condition  has  been  the  subject  of  an  extensive  monograph 
by  Singer  upon  "Pseudo-appendicitis  and  Ileo-caecal  Pain."  Among 
many  other  conditions  which  may  closely  simulate  chronic  ap- 
pendicitis he  has  called  attention  to  distention  of  the  caecum  due, 
in  most  instances,  to  a  spastic  condition  of  the  bowel  lower  down. 
Not  only  does  the  pain  resemble  that  of  (latent)  chronic  appendicitis 
with  no  acute  attacks,  but  there  is  present  tenderness  in  the  right 
iliac  fossa  with  deceptive  phenomena  upon  palpation.  He  gives  as 
the  basis  of  diagnosis  a  careful  investigation  of  the  history,  and  even 
then  it  is  doubtless  difficult  to  distinguish  these  cases.  It  is,  I 
think,  not  as  frequent  as  this  author  would  have  us  believe,  but  I 
feel  that  in  it  we  may  find  the  cause  of  some  unsuccessful  appen- 
dectomies in  supposed  chronic  appendicitis,  where  the  diagnosis 
has  been  made  without  a  history  of  definite  acute  attacks.  Further 
investigation,  however,  is  needed  to  show  us  the  real  frequency  and 
importance  of  the  condition. 

PRIMARY  TYPHLITIS. 

This  condition  was  one  which  in  former  years  was  frequently 
spoken  of  in  the  differential  diagnosis  of  appendicitis.  Mc Williams, 
who  has  written  a  most  thorough  article  upon  the  subject,  defines 
it  as  "A  primary  localized  inflammation  of  the  caecum  which  begins 
in  the  mucosa  and  goes  on  to  ulceration  and  perforation." 


224  Appendicitis 

I  have  yet  to  see  such  a  case.  That  it  may  occur  is  undoubted, 
but  it  is  extremely  rare,  and  as  a  point  to  be  considered  in  the  differ- 
entiation of  appendicitis  it  is  neghgible.  We  have  even  had  reports 
of  such  primary  typhHtis  accompanied  by  the  presence  of  solid 
faeces  in  the  csecum — the  so-called  "stercoral  typhlitis"  of  the  older 
writers.  The  possibility  of  such  a  stercoral  typhlitis  is  too  remote 
to  merit  consideration.  I  have  never  found  solid  fasces  in  the  caecum 
in  an  experience  involving  about  10,000  cases  of  appendicitis. 

CHRONIC    GASTRIC   AND    DUODENAL   ULCER. 

The  role  of  chronic  appendicitis  in  causing  the  symptoms  of 
so-called  dyspepsia  which  are  referred  almost  if  not  quite  entirely 
to  the  upper  abdomen  has  already  been  discussed.  The  differen- 
tiation of  these  obscure  conditions  is  not  always  possible  prior  to 
operation.  Advantage  may  be  taken  of  any  history  of  acute  exacer- 
bations during  which  time  the  true  nature  of  the  affection  is  more 
apparent.  When  the  appendix  is  at  fault  careful  examination 
will  usually  reveal  a  very  slight  rigidity  of  the  muscles  overlying 
the  right  iliac  fossa  as  compared  with  the  left  side.  Tenderness  on 
deep  pressure  over  the  appendix  may  also  be  elicited.  Morris  has 
called  attention  to  tenderness  on  pressure  just  to  the  right  of  the 
umbilicus  over  the  sympathetic  ganglia  as  a  sign  of  chronic  appen- 
dicitis. This  has  not  been  very  helpful  to  me  and  I  can  say  the 
same  of  Rovsing's  sign  which  consists  in  distending  the  caecum  by 
upward  pressure  over  the  descending  colon,  thereby  seeking  to 
bring  out  distention  and  tenderness  of  the  appendix.  The  charac- 
teristic history  of  duodenal  ulcer,  the  intermission  of  symptoms, 
their  distribution,  the  regularity  of  symptoms  in  relation  to  the 
ingestion  of  food,  a  history  of  blood  gross  or  occult  in  the  vomitus, 
stomach  contents  or  stool  must  all  be  kept  in  mind  and  if  present 
with  a  negative  physical  examination  of  the  right  iliac  fossa  organic 
disease  of  the  upper  abdomen  may  be  expected,  but  as  previously 
stated  the  two  conditions  frequently  coexist. 

PERFORATION  OF  GASTROINTESTINAL  ULCERS. 

The  perforation  of  ulcers  of  various  parts  of  the  gastro-intestinal 
tract  may  give  rise  to  symptoms  similar  to  those  of  acute  appendicitis. 


Differential  Diagnosis  225 

We  must  include  in  our  differential  diagnosis  perforation  of  gastric, 
duodenal,  csecal  and  colonic  ulcers  and  those  of  the  small  intestine. 
Typhoid  perforation  has  already  been  discussed  in  the  chapter  on 
Typhoid  Appendicitis. 

Perforated  gastric  and  duodenal  ulcers  present  symptoms  so 
similar  both  before  and  after  the  actual  perforation  that  they  must 
be  considered  together.  In  either  case  the  previous  history  is  of 
great  aid.  As  a  rule  a  patient  with  an  ulcer  of  the  stomach  or 
duodenum  will  have  suffered  for  some  time  previously  with  symp- 
toms referable  to  either  of  these  organs.  By  this  we  must  not  under- 
stand only  the  so-called  classical  symptoms,  such  as  localized  pain, 
vomiting,  haematemesis  and  indigestion,  etc.,  in  the  case  of  gastric 
ulcer,  or  pain  some  time  after  eating,  vomiting,  indigestion  and 
intestinal  haemorrhage  in  the  case  of  duodenal  conditions,  but  also 
the  more  obscure  phenomena.  Many  cases  of  gastric  and  duo- 
denal ulcer  are  "latent"  and  we  have  in  these  no  symptoms  of  dis- 
ease referable  to  the  upper  abdomen.  Many  more,  however, 
formerly  classed  as  latent  are  now  diagnosed  and  treated  before 
the  most  severe  symptoms  and  complications  set  in.  The  more 
careful  taking  of  histories  and  a  better  understanding  of  the  pathol- 
ogy enable  us  now  to  diagnose  many  cases  of  gastric  and  duo- 
denal ulcer  which  formerly  were  treated  for  indigestion,  nervous 
dyspepsia,  etc.  Added  to  this  we  may  note  the  recent  methods  of 
demonstration  of  occult  blood  in  the  stomach  contents  and  faeces. 
In  those  rare  cases  then,  in  which  we  are  confronted  with  the  diffi- 
culty of  distinguishing  between  a  stomach  or  duodenal  perforation 
and  acute  appendicitis  the  history  should  be  most  carefully  con- 
sidered, and  in  the  present  state  of  our  knowledge  should  mean 
much  more  to  us  than  in  former  times. 

The  prodromal  symptoms  of  perforation  of  the  duodenum  or 
stomach  have  been  the  subject  of  increased  investigation  of  late. 
They  may  be  noted  in  the  form  of  vague  feelings  of  increased  epi- 
gastric distress  or  fleeting  pains  of  a  stab-like  character,  often 
brought  on  or  increased  by  deep  breathing  or  any  movement  involv- 
ing the  abdominal  muscles.  Robson  and  Moynihan  mention  a 
patient  who  said  that  it  hurt  her  to  bend,  as  her  side  felt  stiff.  Mr. 
Moynihan  has  lately  laid  stress  on  these  "inaugural  symptoms" 
in  an  admirable  article. 
15 


226  Appendicitis 

When  the  actual  perforation  takes  place  it  is  attended  by  most 
acute  pain  in  the  epigastric  region.  The  pain  is  of  burning  or 
stabbing  character,  and  is  referred  to  the  extreme  upper  abdomen. 
Board-like  rigidity  in  this  region  at  once  follows.  We  may  or  may 
not  have  vomiting,  at  times  bloody.  The  respiration  is  thoracic 
and  rapid  and  the  face  shows  signs  of  extreme  agony.  In  perfor- 
ated duodenal  or  pyloric  ulcer  in  many  instances  the  infection 
rapidly  makes  its  way  downward  toward  the  right  iliac  fossa  and 
if  the  case  is  not  seen  at  once  there  may  be  extreme  tenderness  over 
the  appendiceal  region,  the  whole  picture  suggesting  perforation  of 
the  appendix  with  rapidly  diffusing  peritonitis.  This  error  is  a 
common  one  in  diagnosis.  A  careful  history  is  the  best  safeguard 
but  cannot  insure  against  error.  The  perforation,  however,  may 
be  a  subacute  one  and  all  the  symptoms  be  in  consequence  much 
lessened  in  intensity. 

INTESTINAL  OBSTRUCTION. 

Ordinarily  there  is  little  difficulty  in  distinguishing  intestinal 
obstruction  and  appendicitis.  The  cases  in  which  trouble  arises 
are  the  fulminating  perforations  of  the  appendix  followed  by  rapidly 
spreading  peritonitis  which  quickly  causes  paresis  of  the  bowels  and 
obstipation  as  marked  as  in  any  case  of  mechanical  obstruction. 
At  the  outset  the  diagnosis  is  not  obscure  nor  is  it  difficult  if  a  clear 
history  can  be  obtained  but  in  hospital  practice  one  sees  not  a  few 
cases  of  this  type  in  which  the  patient  on  admission  shows  general 
distention,  diffuse  tenderness  and  reports  absolute  constipation  for 
from  twenty-four  to  seventy-two  hours.  The  region  of  the  appendix 
shows  no  more  marked  signs  than  the  left  iliac  fossa  or  mid-abdomen. 
The  temperature  is  moderately  elevated  and  the  pulse  accelerated 
but  not  more  than  in  the  later  periods  of  obstruction.  Leucocy- 
tosis  is  of  no  assistance  in  differentiation  as  it  occurs  in  both  condi- 
tions. Questioning  will  usually  develop  the  fact  that  in  mechanical 
obstruction  the  pain  at  the  outset  and  for  a  considerable  period 
was  distinctly  colicky  and  remittent  in  type.  Vomiting  is  more 
marked  in  obstruction.  Rigidity  and  tenderness  are  the  chief 
reliances  both  being  much  more  evident  in  peritonitis  than  in 
obstruction. 


Differential  Diagnosis  227 

Intestinal  obstruction  may  occasionally  be  mistaken  for  appen- 
dicitis. The  differential  points  are  the  presence  of  hernia,  of  scar 
indicating  abdominal  operation,  the  colicky  character  of  the  pain, 
slow  pulse  and  normal  or  subnormal  temperature  at  the  outset, 
the  absence  of  true  reflex  rigidity  or  marked  tenderness. 

MALIGNANT   AND   TUBERCULOUS    DISEASE    OF   THE 

C^CUM. 

In  the  early  stages  of  either  malignant  or  tuberculous  disease 
of  the  caecum  it  is  often  impossible  to  differentiate  the  condition 
from  a  chronic  appendicitis;  its  distinction  from  acute  affections  is 
usually  not  difficult  because  of  the  absence  of  the  systemic  signs  of 
acute  infections. 

Carcinoma  may  be  primary  in  the  appendix,  and  when  operation 
is  undertaken  before  further  development  occurs,  the  diagnosis 
can  be  made  only  by  microscopical  examination. 

In  carcinoma  of  the  caecum  there  is  usually  a  history  of  recurrent 
pain  at  the  site  of  the  disease,  and  an  absence  of  inflammatory 
symptoms,  which  strongly  resemble  that  of  a  simple  progressive 
appendicitis  without  acute  attacks.  Blood  examination  is  of  little 
value  except  that  it  may  show  an  anaemia.  Later  on  in  the  disease 
we  may  have  alternating  constipation  and  diarrhoea  with  an  occa- 
sional trace  of  blood  in  the  stools.  The  haemolytic  and  other  labora- 
tory methods  of  diagnosis  of  carcinoma  are  of  no  value  in  this  condi- 
tion. When  a  tumor  is  found  after  the  persistence  of  such  symptoms, 
particularly  if  it  be  hard  or  nodular  and  of  slow  growth,  the  diag- 
nosis of  appendicitis  is  definitely  set  aside.  To  delay  a  differential 
diagnosis  until  this  stage  has  been  reached  is  at  variance  with  all 
principles  of  surgery,  and  it  is  hardly  proper  to  quote  the  signs  of 
a  progression  of  a  growth  to  almost  an  inoperable  stage  as  valuable 
points  in  differential  diagnosis.  The  age  of  the  patient  is  also  a 
most  unreliable  sign  as  carcinoma  of  the  intestines  is  not  rare  in 
the  young. 

Diverticulitis. — Inflammation  originating  in  diverticula  of  the 
large  intestine  may  give  a  picture  in  many  respects  resembling 
appendicitis.  As  the  great  majority  of  such  diverticula  are  situ- 
ated in  the  sigmoid,  the  symptoms  arising  from  diverticulitis  are 


228  Appendicitis 

as  a  rule  left  sided.  It  has  been  described  by  a  patient  as  feeling 
exactly  like  appendicitis  on  the  left  side.  The  disease  occurs,  as  a 
rule,  in  men  past  middle  life  who  have  been  troubled  by  obstinate 
constipation  for  a  considerable  period. 

There  may  be  a  history  of  similar  attacks  of  more  or  less 
severity.  It  is  common  for  an  inflammatory  mass  to  form  which 
may  be  felt  in  the  left  iliac  fossa  or  through  the  rectum  or 
vagina.  In  the  cases  hitherto  reported  the  inflammatory  masses 
generated  by  this  condition  have  frequently  been  of  a  chronic 
character  arid  have  often  been  confused  with  carcinoma.  It  is 
not  uncommon,  however,  for  abscesses  to  form  which  present  the 
same  characteristics  and  expose  the  patient  to  the  same  dangers 
as  appendicular  abscesses,  the  chief  difference  being  in  the  loca- 
tion. An  appendix  abnormally  placed  on  the  left  side  could  sim- 
ulate diverticulitis  in  every  detail.  Pelvic  appendicitis  also  as 
previously  stated  may  give  marked  left-sided  pain  and  tenderness. 

The  question  of  the  existence  of  perforating  ulcer  of  the 
ascending  colon  may  arise  in  the  differential  diagnosis  between 
appendicitis  and  the  previous  conditions.  Ulceration  of  the  colon 
is  most  likely  to  be  associated  with  malignant  disease,  in  which 
event  there  are  present  such  symptoms  as  attacks  of  paroxysmal 
pain,  followed  by  small  bowel  movements,  containing  more  or  less 
mucus,  which  may  be  mixed  with  blood;  the  presence  of  a  mass; 
the  history  of  slow  onset,  and  cachexia.  When  obstruction  exists, 
the  distended  coils  of  intestine  may  be  made  out  during  a  paroxysm 
of  pain  by  examination  of  the  abdominal  wall. 

^Mrs.  R.,  aged  sixty  years,  was  admitted  to  the  German  Hospital  June 
21,  1897.     The  diagnosis  was  carcinoma  of  the  caecum;  ileo-colostomy. 

Her  father  died  of  kidney  trouble;  her  mother  in  childbed.  Five  brothers 
and  two  sisters  were  alive.  She  had  been  married  forty  years  and  had  had 
eight  children.  Menstruation  was  regular  after  marriage.  The  menopause 
occurred  ten  years  ago.  She  had  had  bladder  trouble  for  some  time.  A 
calculus  had  been  removed  from  her  bladder  four  years  ago.  In  December, 
1896,  she  had  the  first  attack  of  her  trouble.  There  developed  severe  lancin- 
ating pain  in  the  right  iliac  fossa,  recurring  at  short  intervals;  since  then  she 
has  passed  scarcely  a  day  without  pain,  sometimes  ha\ang  severe  exacerbations. 
She  has  frequent  micturition,  without  tenesmus,  and  some  ardor  urinae.  She 
states  that  a  small  growth  was  removed  from  her  urethra  in  May,  1897.  There 
has  been  no  hasmaturia.     She  has  passed  gravel  at  times,  but  not  lately.     There 


Differential  Diagnosis  229 

is  considerable  sacral  ache.  Her  appetite  is  good  and  her  bowels  are  regular 
Her  tongue  is  pale,  but  not  coated.  She  has  not  lost  flesh  and  there  is  no  marked 
cachexia. 

Examination  revealed  extreme  tenderness  in  the  right  iliac  fossa,  and  the 
right  rectus  muscle  was  very  rigid,  simulating  a  mass.  There  was  tenderness 
also  on  deep  pressure  in  the  right  vaginal  vault.  The  uterus  was  small  and  atro- 
phied; there  was  no  discharge.  Catheterization  revealed  no  blood,  mucus  nor 
stone  in  the  bladder.     The  urethra  had  evidently  been  dilated. 

Operation. — An  incision  was  made  over  the  region  of  the  appendix.  A  coil 
of  ileum  was  found  to  be  adherent  to  the  caecum.  A  hard  mass  being  felt  above 
the  site  of  the  appendix,  the  appendix  was  exposed  and  found  to  be  completely 
separated  from  its  caecal  attachment.  By  its  removal  with  the  exudate,  a  large 
perforation  was  found  in  the  ileum,  just  above  its  junction  with  the  caecum. 
The  lower  end  of  the  caecum  was  involved  in  a  carcinomatous  growth.  The 
growth  was  removed  by  careful  dissection,  cut  away  with  the  caecum,  and  the 
bowel  closed  with  continuous  silk  suture.  The  terminal  four  inches  of  the 
ileum  were  next  removed,  as  its  mesentery  was  infiltrated.  The  ileum  was 
closed  with  silk  sutures  and  another  portion  anastomosed  with  the  transverse 
colon  by  means  of  a  Murphy  button.     Recovery  was  uneventful. 

Where  no  history  of  previous  disease  of  the  intestines  can  be 
elicited,  acute  perforation,  the  result  of  intestinal  ulceration  or 
rupture,  may  so  closely  resemble  an  attack  of  appendicitis  that  the 
differential  diagnosis  may  be  impossible. 

Ordinarily  in  ulceration  of  the  intestine  there  is  present  an  area 
of  diffuse  pain,  confined  to  that  portion  of  the  abdomen  overlying 
the  site  of  the  affected  bowel.  There  is  also  usually  a  trace  of  blood 
or  slight  intestinal  haemorrhage  (haemorrhoids,  of  course,  being 
excluded),  and  pus  may  be  found  in  the  stools.  There  may  be 
diarrhoea  and  mucous  stools.  These  may,  however,  all  be  absent. 
The  cardinal  symptoms  of  appendicitis  may  be  of  value  in  forming 
a  differential  diagnosis  between  intestinal  perforation  and  appen- 
dicitis, since  in  appendicitis  these  are  usually  well  marked;  they 
may  also,  however,  be  well  marked  in  intestinal  perforation  or  rup- 
ture. The  lesions  in  both  instances  being  similar,  like  symptoms 
are  produced,  particularly  if  the  part  affected  is  the  terminal  por- 
tion of  the  ileum,  the  caecum  or  the  ascending  colon.  The  symp- 
toms of  intestinal  perforation  in  one  previously  well  are  marked: 
namely,  sudden  acute  abdominal  pain,  referable  to  the  seat  of  the 
lesion,  usually  accompanied  by  shock,  which  in  some  instances  is 
very  profound.     There  is  a  leaky  condition  of  the  skin  and  an 


230  Appendicitis 

anxious  expression  of  the  face;  the  pulse  is  rapid  and  thready,  the 
temperature  subnormal.  With  reaction  the  acute  abdominal  pain 
increases,  and,  if  the  case  be  not  recognized  as  an  acute  intestinal 
perforation,  and  cathartics  be  given,  peritonitis  supervenes  more 
rapidly  than  it  would  if  no  laxatives  were  administered. 

Contrast  these  symptoms  with  those  of  early  appendicitis — 
the  acute  abdominal  pain,  the  tenderness,  the  rigidity  of  the  ab- 
dominal walls,  nausea  and  sometimes  vomiting.  Ordinarily  these 
symptoms  occur  after  the  ingestion  of  indigestible  food,  or  after 
exposure  in  some  manner.  The  mere  fact  that  such  conditions 
closely  resemble  each  other,  and  that  it  would  be  impossible  under 
certain  circumstances  to  arrive  at  a  differential  diagnosis  except 
by  operation,  merely  emphasizes  the  propriety  of  operation  in  most 
cases  of  acute  abdominal  disease  having  the  symptoms  of  pain, 
rigidity  and  tenderness  occurring  suddenly  in  one  previously  well. 
The  following  is  a  case  in  point  which  I  deem  of  sufficient  value  to 
relate,  in  order  to  show  the  inability  to  form  a  differential  diagnosis 
at  times  between  this  condition  and  appendicitis. 

M.,  aged  twenty-eight  years,  a  short  time  after  eating  a  hearty  meal  was 
suddenly  seized  with  acute  abdominal  pain.  The  pain  was  referred  to  the 
right  hypochondrium  at  about  the  region  occupied  by  the  gall-bladder.  The 
pain  radiated  from  this  point  to  the  umbilicus;  there  was  nausea  and  vomiting. 
He  took  some  medicine  to  allay  a  sick  stomach.  The  same  evening  a  physician 
was  called,  who  discovered  the  foregoing  state  of  affairs.  There  was  disturbance 
of  the  urinary  secretion,  the  urine  being  highly  colored,  scanty  and  bile-stained. 
A  diagnosis  of  acute  cholecystitis  was  made.  The  patient  was  given  calomel 
in  fractional  doses,  ice  was  applied  to  the  abdomen,  and  milk  with  whiskey  in 
small  quantities  was  given  at  intervals  of  three  hours.  The  following  morning 
the  area  over  the  gall-bladder  was  not  so  sensitive  on  pressure,  nor  quite  so 
rigid  as  the  night  previous.  The  patient  presented  an  anxious  appearance,  the 
skin  was  bluish  and  leaky,  and  there  was  excessive  thirst.  On  account  of  slight 
amelioration  of  the  symptoms  in  the  hypochondriac  region  and  the  patient's 
constitutional  depression,  surgical  interference  was  postponed.  The  same 
evening  the  patient  was  advised  to  go  to  the  hospital  for  operation  on  account 
of  the  symptoms  not  improving.  He  did  not  go,  however,  until  the  following 
morning.  Upon  consultation  the  diagnosis  was  made  of  acute  appendicitis 
with  diffusing  peritonitis.  The  patient's  condition  was  such  that  operation  was 
deferred  until  he  should  react.  The  usual  treatment  for  appendicitis  was  in- 
stituted.    The  patient  died  from  general  peritonitis. 

The  necropsy  revealed  the  appendix  and  gall-bladder  normal.     There  was 


Differential  Diagnosis  231 

a  perforation  of  the  ileum  about  one  and  a  half  to  two  inches  from  its  junction 
with  the  caecum.  The  abdomen  contained  faeces.  The  other  organs  were 
normal. 

The  following  clinical  history  of  a  patient  in  the  service  of  Dr. 
H.  C.  Deaver  at  the  Episcopal  Hospital  is  of  value  as  showing 
the  close  resemblance  to  recurrent  and  relapsing  appendicitis  pre- 
sented by  certain  cases  of  carcinoma  of  the  caecum: 

The  patient,  a  man  of  forty-one  years,  was  first  attacked,  about  three  years 
ago,  with  spasmodic  pain,  rather  dull  in  character,  in  the  right  iliac  fossa.  For 
a  month  or  more  at  a  time  he  would  be  free  from  all  abdominal  symptoms. 
He  was  habitually  constipated,  and  soon  noticed  that  he  was  especially  costive 
before  one  of  these  attacks.  The  pain  of  these  attacks  lasted  as  a  rule  several 
hours,  and  was  accompanied  by  nausea  and  vomiting.  His  appetite  had  been 
failing  for  a  long  time,  and  he  had  been  growing  progressively  weaker  and  more 
anaemic.     He  thought  he  had  lost  forty  pounds  in  weight  in  the  last  three  months. 

Examination  showed  him  to  be  anaemic  and  wasted  in  appearance.  His 
skin  had  a  slightly  yellowish  tinge.  The  chest  presented  no  abnormalities. 
His  abdomen  was  uniformly  rigid  on  palpation,  but  an  indistinct  mass  could 
be  located  on  deep  pressure  over  the  right  iliac  fossa.  Some  tenderness  was 
thus  elicited.  There  was  no  dullness  on  percussion.  The  urine  was  negative. 
Examination  of  the  blood  showed  that  there  were  15,000  leucocytes  and  that 
the  haemoglobin  was  45  per  cent. 

On  the  fifth  of  September,  1904,  the  abdomen  was  opened  over  the  appendix. 
This  was  found  on  examination  to  be  apparently  normal.  A  mass  was  felt, 
however,  in  the  caecum,  which  was  accordingly  delivered  through  the  abdominal 
wound.  The  serous  coat  of  the  caecum  was  smooth  and  unaffected,  but  there 
was  a  carcinoma  involving  the  entire  circumference  of  the  caecum  and  part  of 
the  ascending  colon.  The  tumor  extended  almost  six  inches  longitudinally. 
There  appeared  to  be  almost  complete  obstruction  of  the  lumen  of  the  bowel; 
and  it  became  evident  that  the  periodical  attacks  of  pain,  nausea  and  vomiting 
were  due  to  the  damming  up  of  faeces  on  the  proximal  side  of  the  stricture.  The 
corresponding  mesenteric  glands  were  slightly  enlarged.  This  fact,  together 
with  the  somewhat  wasted  condition  of  the  patient,  made  it  seem  wise  to  perform 
a  palHative  rather  than  a  radical  operation.  Lateral  anastomosis  was  accord- 
ingly done,  with  a  Murphy  button,  between  the  lower  ileum  and  the  ascending 
colon;  and  the  abdominal  wound  closed.  The  progress  of  the  case  after  opera- 
tion was  uneventful.  No  vomiting  occurred;  gas  was  freely  passed  by  the  rec- 
tum; and  the  highest  temperature  recorded  was  99.6°  F.  The  button  was  passed 
by  the  rectum  in  due  time. 

Sarcoma  may  also  occur  in  the  caecum  and  may  closely  resemble 
chronic  appendicitis.  The  symptoms,  however,  approach  more 
nearly  those  of  carcinoma,  though  the  development  may  be  more 


232  Appendicitis 

rapid.  Sarcoma  of  the  ileum  has  also  been  mistaken  for  ap- 
pendicitis. 

Tuberculosis  of  the  caecum  is  practically  always  diagnosed  as 
chronic  appendicitis  before  tumor  formation.  The  vast  majority 
of  cases  of  csecal  tuberculosis,  as  of  other  forms  of  intestinal  tuber- 
culosis, are  secondary,  though  primary  caecal  and  ileo-caecal 
tuberculosis  are  by  no  means  unknown.  Various  types  of  tuber- 
culosis of  this  region  are  described.  The  ulcerative  form,  practi- 
cally always  secondary  to  pulmonary  tuberculosis  usually  occurs 
when  surgical  intervention  is  out  of  the  question,  and  as  a  rule  affects 
the  lower  ileum  and  caecum  simultaneously.  Hypertrophic  tuber- 
culosis is  usually  confined  to  the  caecum  and  232  cases  have  so  far 
been  reported  (Rogers).  It  is  usually  primary  and  until  its  final 
stages  is  largely  confined  to  the  caecum. 

It  will  easily  be  understood  that  in  its  incipiency  the  condition 
will  closely  resemble  chronic  appendicitis.  The  first  symptoms  may 
be  those  of  vague  attacks  of  indigestion  often  accompanied  by 
abdominal  pain  referred  to  the  right  iliac  fossa,  nausea  and  vomiting, 
distention  and  constipation.  When  the  disease  has  not  pro- 
gressed to  the  formation  of  a  palpable  tumor  and  alternate  diarrhoea 
and  constipation  have  not  set  in  a  diagnosis  of  chronic  relapsing 
appendicitis  is  usually  made  and  is  almost  unavoidable.  Subsequent 
developments  will  demonstrate  its  incorrectness  and  fortunately  the 
rarity  of  the  condition  renders  the  necessity  for  such  a  difficult  diag- 
nosis infrequent. 

Tuberculosis  of  the  ilemn  near  the  ileo-caecal  junction  has 
at  times  been  mistaken  for  appendicitis.  Such  a  case  has  come 
under  my  observation. 

Tuberculosis  of  the  Ileo-caecal  Mesenteric  Gland. — ^This 
is  a  condition  occasionally  met  with,  and  in  the  absence  of  asso- 
ciated lesions  elsewhere  gives  rise  to  symptoms  impossible  to  dis- 
tinguish from  those  of  chronic  appendicitis.  Usually  it  is  second- 
ary to  disease  of  the  caecum  or  appendix. 

TYPHOID  FEVER. 

Differentiation  between  typhoid  fever  and  appendicitis  is  an  occa- 
sional source  of  diagnostic  perplexity,  indeed  upon  several  occasions 
I  have  seen  the  surgeon  forced  to  defer  operation  in  appendicitis  be- 


Differential  Diagnosis  233 

cause  the  opinion  of  the  majority  of  the  medical  attendants  was  that 
the  disease  was  typhoid  fever.  Follicular  abscesses  of  the  appendix 
are  responsible  for  some  mistakes  in  the  differential  diagnosis  be- 
tween appendicitis  and  typhoid  fever.  The  minuteness  of  the  collec- 
tions accounts  for  the  mildness  and  the  prolongation  of  the  sepsis  and 
for  the  lessened  degree  of  the  local  symptoms.  In  this  type  of  ap- 
pendicitis there  are  persistent  elaboration  and  continuous  absorption 
of  infectious  products,  with  a  small  amount  of  tissue  involved.  In 
many  respects  the  temperature  record  and  the  general  condition  in 
such  cases  closely  simulate  irregular  typhoid,  and  much  care  in 
examination  is  essential.  It  is  not  uncommon  to  find  supposed 
typhoid  fever  cases  in  which  operation  has  demonstrated  the 
presence  in  the  appendix  of  very  small  follicular  abscesses  varying 
in  size  from  a  millet  seed  to  a  mustard-seed,  an  eroded  mucous 
membrane,  and  a  more  or  less  infiltrated  organ.  In  typical  cases  of 
course  the  symptoms  are  quite  distinct.  Those  of  appendicitis 
have  been  discussed.  Typhoid  fever  ordinarily  has  a  slow  onset, 
attended  by  headache,  lassitude  and  characteristic  tongue  and  tem- 
perature record,  diffuse  abdominal  tenderness  with  relaxation  of 
the  abdominal  walls  and  possible  gurgling  upon  pressure  over  the 
caecum,  with  enlargement  of  the  spleen.  When  such  symptoms 
as  the  latter  are  present  there  can  be  but  little  doubt  as  to  the 
diagnosis,  especially  if  we  have  also  the  typical  eruption.  An 
eruption  is  sometimes  found  in  cases  of  appendicitis  which  may 
resemble  that  of  typhoid  fever,  but  it  occurs  as  a  rule  late,  when 
sepsis  is  far  advanced. 

Our  differential  diagnosis  is  easy  then  with  such  a  clear  history 
of  either  condition  and  when  we  have  the  typical  signs  of  either 
disease  apparent  upon  careful  physical  examination. 

Moreover,  we  have  at  hand  two  most  important  aids  to  diagnosis 
by  laboratory  methods.  The  Widal  reaction  in  typhoid  fever  is 
almost  pathognomonic,  though  its  absence  does  not  imply  the  absence 
of  a  typhoid  infection.  Leucocytosis  is  very  uncommon  in  typhoid 
fever  occurring  only  when  suppurative  complications  exist,  in  fact 
most  cases  show  a  leucopenia  or  diminution  in  the  leucocyte  count. 
The  differential  count  also  shows  a  mononuclear  rather  than  a 
polynuclear  increase.  If  time  permits  a  blood  culture  will  often 
recover  the  typhoid  bacillus. 


234  Appendicitis 

The  diagnosis  between  the  two  conditions  has  been  a  source  of 
difficulty  to  me  only  in  some  of  the  early  stages  of  typhoid  which 
have  had  an  atypical  onset.  In  these  we  do  not  have  a  history  of 
continued  malaise,  etc.,  but  the  disease  seems  to  have  come  on 
more  suddenly,  the  intestinal  distention  causes  some  slight  rigidity 
and  some  tenderness  which  may  be  most  marked  about  the  ileo- 
caecal  region. 

DISEASES  OF  THE  GALL-BLADDER  AND 
BILIARY  DUCTS. 

The  various  diseases  or  rather  inflammations  of  the  gall-bladder 
and  its  associated  ducts  at  times  have  been  a  source  of  confusion 
in  the  diagnosis  of  appendicitis.  We  have  to  consider  practically 
only  the  inflammations,  acute  or  chronic,  calculous  or  non-calculous. 

Before  entering  upon  the  differential  diagnosis  we  must  take 
into  consideration  the  frequent  association  of  appendicitis,  chronic 
or  acute,  with  lesions  of  the  biliary  apparatus.  By  some  authors 
the  appendix  is  considered  the  primary  focus  of  disease,  by  others 
again  the  gall-bladder  is  looked  upon  as  the  initial  seat  of  the  infection. 
Be  that  as  it  may  the  coincident  inflammation  of  the  two  structures 
has  been  noted  by  many  authors,  such  as  Riedel,  Kehr,  Dieulafoy 
and  lately  by  Singer  and  others.  The  latter  author  inclines  to  the 
belief  that  the  gall-bladder  disease  is  primary,  but  offers  no  definite 
proofs.  In  these  cases  we  have  often  alternations  in  the  symptom- 
complex,  in  which  at  times  one  organ,  at  times  the  other  stands 
forth  as  the  one  at  fault,  and  a  number  of  cases  have  been  reported 
in  which  the  diagnosis  was  finally  established  only  by  two  opera- 
tions, the  first,  either  upon  the  gall-bladder  or  appendix,  having 
failed  to  alleviate  the  patient's  distress. 

The  following  case  is  illustrative: 

Some  two  years  since  I  operated  upon  Mrs.  ,  who  was  the  subject  of 

acute  appendicitis,  when  I  found  a  gangrenous  appendix  lying  north.  The 
appendix  being  removed  the  fundus  of  the  gall-bladder  presented;  it  was 
distended,  deeply  injected  with  exudate  surrounding  it.  While  the  gall-bladder 
was  found  in  an  inflammatory  condition  I  did  not  disturb  it.  On  the  seven- 
teenth day  after  the  appendix  operation,  however,  it  broke  down  and  discharged 
its  contents,  pus  with  bile  and  finally  pure  bile.  The  sinus  closed  in  a  com- 
paratively short  time,  the  patient  recovered  promptly  and  remains  well. 


Differential  Diagnosis  235 

EMPYEMA  OF  THE  GALL-BLADDER. 

In  discussing  the  affections  of  the  gall-bladder  in  their  relation 
to  appendicitis,  they  may  be  classed  into  two  general  groups.  First, 
the  acute  inflammations,  which  include  acute  phlegmonous  or  gan- 
grenous cholecystitis  and  empyema  of  the  gall-bladder,  any  of 
which  may  be  associated  with  the  presence  of  gall-stones;  and 
cholelithiasis  by  which  we  may  understand  gall-stone  disease 
unattended  by  the  more  acute  manifestations. 

Acute  cholecystitis  of  whatever  variety  is  to  be  distinguished 
from  acute  appendicitis  not  so  much  by  the  onset  which  in  either 
case  is  liable  to  be  sudden  and  accompanied  by  fever  and  leuco- 
cytosis,  but  by  the  absence  of  the  typical  arrangement  of  symptoms 
found  in  appendicitis  and  the  very  definite  signs  which  point  to  a 
lesion  of  the  biliary  tract.  There  may  be  a  history  of  previous 
similar  attacks  with  possible  transient  jaundice;  and  the  attacks 
more  frequently  follow  indiscretions  in  eating  and  drinking  than 
is  the  case  in  appendicitis,  because  a  duodenal  catarrh  is  a  fertile 
cause  of  obstruction  of  the  duct  and  the  extension  of  infection.  The 
pain  is  from  the  first  more  or  less  sharply  localized  to  the  right 
epigastrium  and  sometimes  radiates  to  the  right  shoulder  or  back. 
The  tenderness  and  rigidity  are  also  found  only  about  the  gall- 
bladder region.  Jaundice  may  be  present  but  too  much  stress 
must  not  be  laid  upon  its  diagnostic  value  as  it  is  frequently  entirely 
absent  in  all  the  varieties  of  gall-bladder  disease. 

When  the  cysticus  becomes  obstructed  the  gall-bladder  may 
become  distended.  In  such  cases,  when  the  rigidity  and  tender- 
ness do  not  prevent  accurate  palpation  the  gall-bladder  may 
be  felt  as  a  round,  tense,  markedly  tender  tumor  moving  with  res- 
piration, beneath  the  liver  margin. 

Empyema  of  the  gall-bladder  is  but  a  further  development  of 
a  simple  or  mild  cholecystitis  in  which  we  have  a  frankly  purulent 
and  severe  inflammation  of  the  viscus  with  obstruction  of  the  cystic 
duct.  It  presents  the  same  symptoms  and  diagnostic  points  in 
more  marked  degree  and  the  marked  constitutional  disturbances 
and  localized  pericholecystitis  so  often  present  render  differentia- 
tion correspondingly  easier. 

Acute  phlegmonous  or  gangrenous  cholecystitis  is  the  last 


236  Appendicitis 

and  most  severe  degree  of  gall-bladder  inflammation.  Its  well 
marked  symptoms  leave  us  as  a  rule  but  few  doubts  as  to  the 
diagnosis. 

If  the  gall-bladder  ruptures,  the  pus  may,  in  some  instances, 
gravitate  toward  the  right  iliac  fossa  and  give  rise  to  the  supposition 
that  this  was  the  original  location  of  the  inflammatory  process.  The 
differential  diagnosis  between  a  ruptured  empyema  of  the  gall- 
bladder and  a  ruptured  appendiceal  abscess  may  be  extremely 
difficult  as  the  rapidly  spreading  peritonitis  obscures  our  land 
marks.  The  points  to  be  noted  are  the  previous  history  and  the 
fact  that  in  cases  of  ruptured  gall-bladder  the  rigidity  is  most 
marked  in  the  upper  portion  of  the  right  rectus  muscle. 

Cholelithiasis  would  at  first  thought  seem  easy  to  differentiate 
from  appendicitis,  yet  this  is  not  always  the  case.  It  must  be 
remembered  that  in  perhaps  the  vast  majority  of  gall-stone  cases 
the  symptoms  are  not  the  classical  ones  of  the  disease,  certainly 
not  when  they  first  begin  to  manifest  themselves.  The  vague  diges- 
tive disturbances,  absence  of  jaundice  and  of  characteristic  pain 
will  often  lead  us  to  think  of  an  indigestion  caused  by  a  chronic 
appendicitis.  Then  again,  the  symptoms  directly  referable  to  the 
gall-bladder  may  be  entirely  absent,  while  the  pain  may  be  entirely 
referred  to  the  ileo-caecal  region.  This  referred  pain,  when  accom- 
panied by  constipation  and  secondary  caecal  distention,  may  so 
closely  simulate  a  chronic  appendicitis  as  to  mislead  us  entirely. 
Singer  has  quoted  such  a  case  in  which,  from  his  description, 
it  is  evident  that  the  utmost  refinements  of  diagnostic  ability 
failed  to  render  the  condition  clear  until  subsequent  developments 
called  attention  to  the  gall-bladder  trouble. 

Typical  biliary  colic  with  its  sharp  localization  and  radiation, 
and  accompanying  jaundice  should  not  offer  any  diagnostic  diffi- 
culties as  far  as  appendicitis  is  concerned. 

Hepatic  and  perihepatic  abscess  could  be  confounded  with 
appendicitis  only  when  in  the  latter  there  is,  late  in  the  disease,  a 
circumscribed  collection  of  pus  in  close  relation  with  an  appendix 
which  holds  a  post-colic  position  and  points  toward  the  liver. 

Acute  Pancreatitis. — ^This  disease  is  distinguished  from  appen- 
dicitis by  the  greater  severity  of  its  onset  and  course,  persistent 
vomiting,  localization  of  tenderness  and  tumescence  in  the  epi- 


Differential  Diagnosis  237 

gastrium,  followed  frequently  in  the  less  severe  cases  by  pain, 
swelling  and  tenderness  in  the  left  loin.  Hiccough,  limitation  of 
diaphragmatic  movement  and  the  signs  of  basal  pulmonary  involve- 
ment are  also  common.  The  course  of  the  inflammatory  involve- 
ment of  the  peritoneum  is  from  above  downward  rather  than  from 
below  upward  as  in  the  case  of  appendicitis.  The  history  is  of 
importance.  Confusion  is  likely  to  arise  only  in  those  cases  which 
are  seen  after  peritonitis  is  fully  established  and  in  such  cases  full 
importance  must  be  given  to  the  sequence  of  events  which  have 
preceded. 

Chronic  pancreatitis  occurs  in  old^r  individuals  as  a  rule  who 
have  had  a  history  of  long-standing  indigestion  of  upper  abdominal 
type.  It  is  to  be  confused  chiefly  with  latent  appendicitis  which 
refers  its  symptoms  entirely  to  the  upper  abdomen.  The  distinc- 
tion is  not  always  to  be  made  clinically  but  an  opinion  may  usually 
be  formed  by  careful  examination  of  the  region  of  the  appendix 
confirming  or  tending  to  eliminate  the  role  of  that  organ  and  by  the 
various  tests  of  pancreatic  function  with  examination  of  the  urine 
for  sugar  and  by  the  development  of  any  history  of  jaundice.  Un- 
fortunately for  diagnosis  but  fortunately  for  individuals  who  are 
the  subject  of  chronic  pancreatitis,  the  diseased  pancreas  may 
still  supply  its  essential  ferments  to  the  digestive  tract.  Deduc- 
tions based  upon  the  tests  for  the  demonstration  of  these  ferments 
must  be  accepted  with  caution.  Conclusive  differential  diagnosis 
must  often  rest  upon  the  findings  at  operation. 


RENAL  IRRITATION  BY  APPENDICITIS. 

Too  much  stress  cannot  be  laid  upon  the  importance  of  urinary 
examinations,  not  only  in  all  kidney  affections,  but  also  in  cases  of 
appendicitis. 

In  most  cases  of  appendicitis  examination  of  the  urine  reveals 
slight  abnormalities,  such  as  traces  of  albumin,  cylindroids,  hya- 
line casts,  renal  and  ureteral  epithelium,  leucocytes  and,  rarely, 
red  blood  corpuscles.  In  the  affections  in  which  the  kidney  and 
its  adnexa  are  involved  early  the  urine  will  show  characteristic 
peculiarities. 


238  Appendicitis 

MOVABLE  KIDNEY. 

Movable  kidney  is  indicated  by  the  presence  of  a  movable  tumor 
characteristic  in  shape,  which  by  properly  directed  pressure  can  be 
restored  to  its  normal  position.  The  methods  of  palpating  a  floating 
kidney  are  well  known  and  need  not  be  dwelt  upon  here.  The 
condition,  except  under  exceptional  circumstances  will  not  give  rise 
to  such  symptoms  that  acute  appendicitis  will  be  suspected,  but 
the  repeated  attacks  of  pain  associated  with  the  condition  may 
give  rise  to  a  suspicion  of  chronic  appendicitis.  The  associated 
neurasthenic  condition  and  frequent  general  visceral  ptosis  should 
put  us  on  our  guard  at  once.  The  urinary  disturbances  which 
accompany  malposition  of  the  kidney,  the  frequent  desire  to  urinate 
with  the  excretion  of  an  excessive  amount  of  urine  would  lead  us  to 
examine  the  patient  more  closely.  While  fever  and  chills  may  ac- 
company the  crises  of  pain  they  are  rare  and  we  have  not  the  charac- 
teristic sequence  of  symptoms  that  we  find  in  appendicitis,  nor  do 
we  have  a  leucocytosis.  Rigidity  and  tenderness  may  be  found 
when  we  have  a  loose  kidney  but  their  location  and  extent  would  at 
once  show  that  they  are  not  appendiceal  in  origin. 

The  operator  may  be  thrown  off  his  guard  by  acute  indigestion 
occurring  in  a  nervous  individual  suffering  at  the  same  time  from 
acute  paroxysms  of  pain  due  to  movable  kidney,  which  was  previously 
not  recognized  by  the  patient  or  physician.  Under  these  circum- 
stances the  kidney  may  become  temporarily  anchored  in  its  abnormal 
position.  Under  the  foregoing  conditions  I  have  been  called  upon 
to  operate  for  acute  appendicitis,  and  could  not  say  definitely 
that  the  case  was  not  acute  appendicitis  until  the  patient  was  fully 
anaesthetized;  then,  upon  palpation,  the  diagnosis  at  once  became 
clear.  Again,  in  the  presence  of  both  conditions — i.  e.,  movable 
kidney  with  acute  symptoms  and  an  enlarged  appendix  due  to 
chronic  inflammation — examination  under  ether  will  disclose  not 
only  the  abnormal  condition  of  the  kidney,  but  also  the  presence  of 
a  palpably  enlarged  appendix.  If,  under  these  circumstances  the 
patient  has  been  suitably  prepared,  an  appendicular  operation 
should  be  performed. 

Edebohls,  in  a  series  of  interesting  papers,  has  insisted  upon 
movable  kidney  as  a  cause  of  appendicitis.     He  claims  that  a  mov- 


Differential  Diagnosis  239 

able  kidney,  by  dislocating  the  duodenum  and  pancreas,  compresses 
the  superior  mesenteric  vessels  and  thus  causes  chronic  passive  con- 
gestion of  the  appendix,  since  its  blood  is  returned  through  the  su- 
perior mesenteric  vein.  Movable  kidney  being  more  frequent  among 
women,  he  thinks  that  of  100  women  with  chronic  appendicitis,  81 
have  movable  right  kidney  as  well,  and  that  therefore  treatment  of 
either  disease  alone  will  be  ineffectual  in  relieving  the  symptoms; 
hence  he  proposes  and  has  practised  the  performance  of  nephropexy 
and  appendectomy  through  the  same  lumbar  incision.  Only  in  a 
few  cases  has  he  found  it  impossible  to  reach  the  appendix  through 
this  wound.  Personally  I  think  such  an  operation  is  a  dangerous 
procedure  and  cannot  recommend  it,  as  I  regard  separate  incisions 
for  the  appendix  and  kidney  operations  a  far  safer  method.  I  do 
not  believe  that  Edebohl's  explanation  of  pain  in  the  region  of  the 
appendix  is  always  correct  nor  that  the  appendix  should  be  removed 
in  the  large  percentage  of  cases  of  movable  kidney  which  he  advo- 
cates. I  consider  that  the  pain  in  the  right  iliac  fossa  and  the  ten- 
derness that  can  be  elicited  by  palpation  over  the  region  to  which  the 
pain  is  referred  can  better  be  explained  by  colic  due  to  the  pressure  of 
the  displaced  kidney  against  the  colon.  I  have  been  able  to  dem- 
onstrate this  in  a  number  of  cases  where  fixation  of  the  kidney  alone 
has   relieved    the    symptoms   referable    to   the   right  iliac  fossa. 

DISEASES  OF  THE  KIDNEYS  AND  URETERS. 

The  occasions  when  we  are  called  upon  to  differentiate  between 
acute  or  chronic  appendicitis  and  a  lesion  of  the  kidney  or  ureter  are 
not  frequent.  When,  however,  such  is  the  case  the  diagnosis  may 
be  one  of  great  difficulty.  The  structures  upon  the  right  side  alone 
must  be  taken  into  account  in  the  differentiation  and  the  affections 
of  the  kidney  or  ureter  which  obscure  the  diagnosis  may  be  either 
inflammatory,  calculous  disease,  or  the  result  of  alterations  in  the 
location  of  the  kidney  itself.  Neoplasms  of  the  kidney  also  may 
call  for  consideration  in  exceptional  instances. 

The  inflammatory  affections  concerning  the  kidney  which  may 
be  confused  with  appendicitis  are  pyo-nephrosis,  perinephritic 
abscess  and  multiple  abscess  of  the  kidney. 

Pyo-nephrosis  differs  from  appendicitis  in  such  marked  degree 


240  Appendicitis 

that  a  diagnosis  should  seldom  be  difficult.  Its  onset  is  gradual, 
the  pain  radiates  from  the  loin  to  the  umbilical  region,  groin  and 
testicle,  and  retraction  of  the  latter  may  occur.  Palpation  of  a  tender 
mass  which  moves  with  and  is  continuous  with  the  kidney  is  the  most 
reliable  local  sign  of  abscess  of  the  kidney,  while  irritability  of  the 
bladder  and  the  presence  of  pus  and  possibly  blood  in  the  urine  are 
important  confirmatory  signs.  In  every  case  where  a  kidney  lesion 
may  be  suspected  a  cystoscopic  examination  with  catheterization 
of  the  ureters  should  be  undertaken. 

Septic  Infarcts  or  haematogenous  infection  of  the  right  kidney 
may  simulate  appendicitis.  The  urinary  and  physical  findings  are 
distinctive. 

Ureteritis. — Inflammation  of  the  ureter  may  occur  either  as  a 
sequel  to  inflammation  of  the  bladder  or  in  connection  with  disease 
of  the  kidney.  The  differential  points  are :  The  history,  the  presence 
of  tenderness  at  the  bladder  extremity  of  the  ureter,  as  made  out  by 
vaginal  or  rectal  examination;  the  presence  of  deep-seated  tender- 
ness along  the  line  of  the  ureter;  and  the  presence  in  the  urine  of  pus 
and  blood.  Cystoscopic  examination  will  show  a  pouting  inflamed 
ureteral  orifice,  possibly  discharging  pus,  and  if  supplemented  by 
catheterization  of  the  ureter  will  make  the  diagnosis  clear. 

Renal  and  Ureteral  Calculus. — Ordinarily  the  symptoms  of 
stone  in  the  upper  urinary  tract  are  sufficiently  distinctive  to  avoid 
confusion.  In  the  absence  of  definite  renal  colic  with  its  character- 
istic radiations,  however,  the  pain  may  strongly  suggest  chronic 
appendicitis  and  if  the  stone  be  in  the  lower  ureter  there  may  be 
tenderness  in  the  region  of  the  appendix.  I  have  encountered  one 
such  case  in  a  woman  who  had  already  had  the  appendix  removed 
and  subsequently  underwent  a  pelvic  operation  for  pain  localized  in 
the  right  iliac  fossa.  The  explanation  of  the  symptoms  proved  to  be 
a  small  calculus  lodged  in  the  ureter  just  above  the  pelvic  brim.  No 
true  renal  colic  had  ever  been  present  and  the  tenderness  was  so 
situated  as  to  be    indistinguishable  from  that  due  to  the  appendix. 

X-ray  examination  should  be  made  in  all  doubtful  cases  and  often 
ureteral  catheterization  will  settle  the  point,  though  this  is  not  to 
be  employed  routinely  but  only  when  there  is  a  well-founded  sus- 
picion of  renal  or  ureteral  disease. 

Renal  colic  should  hardly  cause  confusion  in  the  diagnosis  of 


Differential  Diagnosis  241 

appendicitis  except  in  those  instances  in  which  an  inflammation  of 
the  appendix  is  associated  with  pain  referred  to  the  umbiHcus  and 
also  with  vesical  symptoms,  such  as  tenesmus  and  frequent  mic- 
turition. When  the  appendix  is  pelvic  and  adherent  to  the  bladder 
these  symptoms  may  be  prominent,  but  on  the  other  hand  symptoms 
referable  to  the  loin  will  probably  be  absent.  The  X-ray  is  of  great 
value  in  diagnosing  small  kidney  or  ureteral  stones,  and  in  connection 
with  catheterization  of  the  ureters  in  doubtful  cases  will  positively 
determine  the  presence  or  absence  of  an  obstruction  in  that  canal. 

Toxic  nephritis  accompanying  appendicitis  and  obscuring  the 
diagnosis  has  been  found.  In  rare  instances  also  a  direct  com- 
munication between  an  inflamed  appendix  and  the  pelvis  of  the 
kidney  or  ureter  may  bring  the  urinary  phenomena  into  the  fore- 
ground in  a  manner  apt  to  mislead  us. 

I  have  operated  upon  a  patient  whose  urine  contained  pus  and 
epithelium  from  the  pelvis  of  the  ureter.  There  was  present  swell- 
ing in  the  right  loin,  and  tenderness  which  extended  in  the  direc- 
tion of  the  attachment  of  the  appendix;  and  the  history  of  the  three 
cardinal  symptoms  of  appendicitis  was  elicited.  The  right  iliac 
fossa  was  opened.  The  appendix,  which  pointed  north,  was  post- 
colic  and  contained  pus.  It  was  adherent  to  and  in  communication 
with,  the  pelvis  of  the  ureter  (kidney),  through  which  the  contents 
of  the  appendix  were  being  emptied  into  the  bladder,  thus  explain- 
ing the  urinary  symptoms.  The  recovery  was  uneventful.  Bevan 
reports  a  case  where  sharp  pain  in  the  lower  abdomen  was  followed 
by  a  microscopic  amount  of  blood  in  the  urine;  a  diagnosis  of  renal 
colic  was  made,  but  when,  a  few  days  later,  an  abscess  formed 
around  the  appendix,  this  organ  was  removed  and  proved  to  be  the 
true  seat  of  the  disease. 

FLOATING   KIDNEY  WITH   A   TWISTED   URETER. 

Floating  kidney  with  a  twisted  pedicle  may  cause  abdominal 
pain,  nausea,  vomiting,  and  chills  and  fever,  which  symptoms  may 
suggest  appendicitis.  This  condition  may  be  diagnosticated  from 
appendicitis  by  pain  which  radiates  in  the  line  of  the  ureter  and  is 
not  increased  to  any  marked  degree  by  pressure;  a  history  of  a 
16 


242  Appendicitis 

movable  tumor  prior  to  the  attack;  the  presence  of  blood  in  the 
urine;  and  absence  of  the  cardinal  symptoms  of  appendicitis. 

In  the  absence  of  urinary  symptoms  abscess  of  the  kidney, 
particularly  if  it  be  a  floating  kidney,  necessarily  presents  greater 
difficulty  in  differentiation.  In  the  latter  instance,  however,  the 
tumor  will  be  movable.  I  have  operated  on  a  case  of  acute  suppura- 
tion of  the  kidney  in  which  the  urine  was  normal  and  the  diagnosis 
was  made  on  the  anatomical  situation  of  the  swelling,  in  the  ab- 
sence of  the  characteristic  symptoms  of  appendicular  inflammation. 

PERINEPHRIC  ABSCESS. 

When  the  appendix  holds  a  retro-colic  position  or  occupies  the 
ileo-caecal  or  subcaecal  fossa,  and  inflammation  of  the  organ  has  pro- 
gressed to  the  formation  of  pus,  the  collection  may  be  mistaken  for 
a  perinephric  abscess.  The  presence  of  intestinal  disturbance  and 
of  the  cardinal  symptoms  of  appendicitis,  however,  should  be 
sufficient  to  justify  a  diagnosis  of  appendicitis.  When  the  appen- 
dicular abscess  is  in  relation  with  the  right  kidney,  an  incision 
through  the  loin,  such  as  is  made  for  the  evacuation  of  a  perinephric 
collection,  may  be  followed  by  the  discharge  of  purulent  matter. 
It  must  be  borne  in  mind,  however,  that  the  evacuation  of  a  supposed 
perinephric  abscess  in  this  manner  does  not  prove  that  the  collection 
of  pus  was  not  in  reality  of  appendicular  origin.  A  case  in  point  is 
the  following: 

The  original  diagnosis  was  appendicitis,  and  on  account  of  the  desperate 
condition  of  the  patient,  an  incision  for  the  evacuation  of  the  collection  was 
made  through  the  loin.  Recovery,  with  repair  of  the  wound  followed.  The 
patient,  however,  was  unable  to  resume  his  occupation  on  account  of  localized 
pain,  referred  to  and  above  the  posterior  half  of  the  crest  of  the  ilium.  Six 
weeks  after  recovery  from  the  operation  for  the  evacuation  of  the  abscess  he 
Was  again  referred  to  me.  Upon  examination  the  incision  was  found  intact, 
but  tender.  Upon  palpation  of  the  tender  point  distinct  resistance  was  noted. 
Removal  of  the  appendix  was  recommended.  When  the  patient  was  under  the 
anaesthetic  and  was  being  placed  upon  the  operating  table,  a  distinct  faecal 
odor,  which  was  thought  to  be  due  to  a  bowel  movement,  was  noticed.  Upon 
the  removal  of  the  antiseptic  dressing  which  covered  the  proposed  field  of  opera- 
tion it  was  found  that  the  cicatrix  had  broken  down  at  one  point  and  that  fascal 
matter  was  escaping  from  it.     Believing  this  to  be  a  fsecal  fistula,  the  result  of 


Differential  Diagnosis  243 

an  original  attack  of  appendicitis,  I  opened  the  abdomen,  isolated  the  field  of 
operation  by  gauze  packing,  and  located  the  appendix.  The  tip  of  the  organ 
was  perforated  and  its  lumen  was  found  to  be  in  direct  communication  with  the 
fascal  fistula.  The  appendix  was  removed  and  the  wound  was  treated  in  the 
usual  manner.     I  have  treated  other  cases  of  like  character. 

Suppuration  at  the  internal  abdominal  ring  may  closely  simulate 
acute  appendicitis.  The  existence  of  urethritis  or  epididymitis,  the 
usual  absence  of  vomiting  and  intestinal  symptoms,  and  the  location 
of  the  pain  and  tenderness  may  suffice  to  differentiate  the  condition. 

EXTRA-UTERINE  PREGNANCY. 

The  history  of  cases  of  extra-uterine  pregnancy  is  usually  that 
of  partial  or  complete  cessation  of  the  menstrual  flow  for  one,  two 
or  more  periods,  generally  accompanied  by  other  symptoms  of 
pregnancy,  and  collapse  supervening  upon  an  attack  of  acute 
abdominal  pain.  The  pain  is  long  continued  and  paroxysmal,  but 
not  of  the  nature  of  intestinal  colic.  An  irregular,  bloody,  vaginal 
discharge,  generally  lighter  in  color  than  the  normal  menstrual  flow, 
and  containing  shreds  of  tissue — ^portions  of  the  decidua — is  present. 
Vaginal  examination  reveals  a  tender  and  sensitive  mass  in  Douglas's 
cul-de-sac,  unless  the  pregnancy  be  an  abdominal  one.  In  the 
majority  of  these  cases  there  is  a  history  of  sterility  for  five  or  six 
years  previous  to  the  abnormal  conception.  If  rupture  should 
occur  and  the  resulting  haematocele  become  infected  the  diagnosis 
is  rendered  more  difficult,  unless  the  patient  can  give  a  clear  de- 
scription of  the  character  of  the  pain  and  the  collapse  at  the  time  of 
rupture.  In  a  robust  individual  the  anaemia  and  weakness  would  be 
more  marked  than  in  appendiceal  disease. 

In  the  case  of  pelvic  haematocele  consequent  on  ruptured  extra- 
uterine pregnancy  becoming  infected  the  interval  between  the  rupture 
and  the  infection  will  necessarily  be  longer  than  that  between  the 
onset  of  the  attack  of  appendicitis  and  the  formation  of  pus.  It  is 
very  important  here,  as  in  all  cases,  to  elicit  a  most  careful  history. 

When  the  product  of  conception  occupies  the  fimbriated  ex- 
tremity of  the  right  tube,  the  points  of  differentiation  are  more  diffi- 
cult, owing  to  the  close  proximity  of  the  lesion  to  the  appendix,  and 
the  negative  result  of  examination  per  vaginam  prior  to  rupture. 
Should  the  two  conditions  occur  coincidently,  it  will  be  well  nigh 


244  Appendicitis 

impossible  to  differentiate  between  them".  The  chief  points  to  be 
borne  in  mind,  however,  are  the  history,  the  absence  of  inflammatory 
symptoms  prior  to  the  rupture  of  the  extra-uterine  sac,  and  the 
presence  of  inflammatory  symptoms  in  appendicitis.  Appendicitis 
complicated  by  normal  pregnancy  in  its  early  stages  has  been 
mistaken  for  extra-uterine  pregnancy,  yet  the  normal  birth  of  a 
child  within  a  reasonably  short  time  previous,  and  the  absence  of 
decidual  discharge  from  the  vagina,  should  incline  the  diagnosis  to 
appendicitis. 

DISEASES   OF   THE  FEMALE  PELVIC   ORGANS. 

Various  organic  and  functional  abnormalities  of  the  female  genital 
organs  give  rise  at  times  to  errors  in  the  diagnosis  of  appendicitis. 

The  functional  disturbances  are  those  associated  with  painful 
menstruation  and  the  menopause. 

Dysmenorrhoea  may  be  mistaken  for  appendicitis  or  vice  versa. 
An  inquiry  into  the  history  of  the  case  and  careful  examination 
will  leave  but  little  doubt  as  to  the  diagnosis.  Pelvic  examinations 
should  not  be  neglected.  McRae  has  called  attention  to  the  fre- 
quency with  which  painful  menstruation  obscures  appendicitis, 
and  is  of  the  opinion  that  many  such  patients  would  be  cured  by 
the  removal  of  their  appendices. 

Menopause. — During  this  period  the  gastric  disturbances  with 
the  associated  hysterical  and  neurasthenic  manifestations  may 
give  rise  to  symptoms  suggestive  of  appendicitis,  but  hardly  to  such 
an  extent  as  to  lead  us  to  this  mistaken  diagnosis. 

Acute  salpingitis  is  very  similar  in  its  symptoms  to  appen- 
dicitis, especially  if  it  be  confined  to  the  right  side.  The  history 
of  an  infection  aids  us  when  it  is  positive,  its  absence  means  nothing. 
The  disease  differs,  however,  in  its  mode  of  onset.  The  pain  and 
rigidity  are  low  down,  the  latter  not  so  early  or  so  marked  as  in 
acute  appendicitis.  The  gastro-intestinal  symptoms,  vomiting, 
etc.,  are  as  a  rule  absent.  The  most  tender  point,  as  in  all  affec- 
tions of  the  uterine  appendages,  is  just  above  the  middle  of  Pou- 
part's  ligament,  while  in  appendicitis  it  is  in  the  right  iliac  fossa. 
Vaginal  examination  is  of  great  aid.  The  tenderness  in  the  right 
vaginal  fornix  need,  however,  not  necessarily  be  due  to  an  inflam- 


Differential  Diagnosis  245 

mation  of  the  adnexa,  but  may  be  caused  by  an  acutely  inflamed 
appendix  placed  in  the  pelvis.  The  relation  of  the  tender  point 
to  the  uterus  will,  however,  enable  us  in  most  instances  to  deter- 
mine definitely  whether  it  arises  from  the  tube  and  ovary  or  the 
appendix.  When  vaginal  examination  is  negative  as  to  the  pres- 
ence of  a  tender  or  congested  area  salpingitis  may  be  excluded.  It 
must  be  remembered  that  it  is  not  very  infrequent  for  the  tube  and 
ovary  to  become  adherent  to  the  appendix  as  a  result  of  appendicitis. 

PYO-SALPINX  AND  OVARIAN  ABSCESS. 

The  presence  in  the  recto-uterine  cul-de-sac,  in  intimate  relation 
with  the  uterus,  of  an  inflammatory  mass  which  renders  the  uterus 
partly  or  completely  immovable,  and  which  can  be  clearly  outlined 
by  vaginal,  bimanual,  or  combined  vaginal  and  rectal  examination, 
together  with  a  history  of  a  vagino-uterine  infection,  especially 
gonorrhoea,  and  the  presence  of  a  septic  fever,  establishes  the  diag- 
nosis of  pyo-salpinx  or  of  tubo-ovarian  or  ovarian  abscess.  Still, 
an  inflamed  appendix  directed  into  the  pelvis,  and  lying  in  relation 
with  or  adherent  to  the  right  tube  and  ovary,  will  simulate  pyo- 
salpinx  or  tubo-ovarian  or  ovarian  abscess  of  the  right  side  in  that 
there  will  be  an  inflammatory  mass  near  the  uterus,  and  pain  and 
tenderness  upon  vaginal  or  rectal  examination,  or  both.  The 
diagnosis  of  appendicitis  will  be  established  if  there  can  be  obtained 
a  history  of  previous  attacks,  characterized  by  a  sudden  onset  of 
abdominal  pain,  usually  becoming  localized  in  the  right  iliac  fossa, 
and  rigidity  of  the  abdominal  wall.  Tenderness  in  the  right  iliac 
fossa  is  present  in  both  diseases,  but  in  appendicitis  the  tender  area 
occupies  the  higher  position. 

OOPHORITIS. 

Inflammation  of  the  right  ovary  may  be  confounded  with 
appendicitis,  as  it  is  attended  with  pain,  tenderness  in  the  right 
iliac  fossa,  nausea  and  fever.  It  is  always,  however,  accompanied 
by  disturbances  of  the  uterine  functions,  and  is  demonstrated  by 
vaginal  or  bimanual  examination.  The  pain  in  appendicitis  is  at 
first  in  the  peri-umbflical  or  epigastric  region,  and  becomes  localized 


246  Appendicitis 

in  the  right  iliac  fossa.  The  tender  area  in  appendicitis  is  situated 
in  the  iliac  fossa,  further  to  the  right  than  in  inflammation  of  the 
ovary,  whereas  in  the  ovarian  affection  the  tenderness  is  never  so 
intense  as  in  appendicitis,  and  is  not  accompanied  by  a  perceptibly 
enlarged  appendix. 

SUPPURATING  OVARIAN  CYST. 

An  appendicular  abscess  and  a  suppurating  ovarian  cyst  on 
the  right  side  present  some  symptoms  in  common  which  may  give 
rise  to  difficulties  in  diagnosis.  There  are  found  a  painful  tumor 
in  the  right  iliac  fossa,  which  may  be  made  out  by  vaginal,  bimanual, 
and  external  examinations;  vague  symptoms  of  septicaemia;  hectic 
temperature;  and  a  history  of  previous  gastric  and  urinary  irrita- 
tion. By  careful  consideration,  however,  the  differences  are  suffi- 
ciently marked.  In  ovarian  cyst  the  onset  is  gradual,  and  a  history 
of  some  infection  can  generally  be  elicited.  The  pain  is  constant 
and  dull  in  character;  by  pressure  the  significant  "ovarian  pain," 
which  differs  from  the  colicky  appendicular  paroxysms,  may  be 
produced,  the  rigidity  of  the  abdominal  walls  is  not  so  marked  as  in 
appendicitis,  while  the  tumor  itself  is  more  elastic,  less  firmly  fixed, 
and  apparently  has  thinner  walls  and  a  more  regular  outline.  If 
the  abscess  be  of  appendicular  orign,  there  usually  will  be  a  history 
of  one  of  more  attacks  which  presented  the  characteristic  symptoms 
of  appendicitis,  while  if  ovarian  these  will  be  absent. 

OVARIAN  CYST  WITH  TWISTED  PEDICLE. 

An  ovarian  cyst  with  a  twisted  pedicle  gives,  at  times,  a  history 
of  a  slowly  growing  tumor,  but  is  so  frequently  unaccompanied 
by  pain  that  its  presence  is  often  unsuspected  until  the  accident 
occurs.  The  onset  of  the  acute  symptoms  of  a  cyst  with  a  twisted 
pedicle  is  sudden,  and  is  usually  caused  by  an  excessive  peristalsis 
of  the  intestines  or  by  sudden  change  of  the  position  of  the  body, 
causing  the  tumor  to  rotate  on  its  pedicle.  A  migrated  daughter 
cyst  becoming  attached  to  the  omentum  in  the  neighborhood  of 
the  caecum,  has,  on  its  pedicle  becoming  twisted,  very  closely  simu- 
lated appendicitis  (Brewer).'     If  the  twisting  be  complete  enough 


Differential  Diagnosis  247 

to  shut  off  the  circulation,  the  walls  of  the  cyst  quickly  become 
gangrenous,  and  the  patient's  condition  rapidly  grows  profoundly 
septic,  while  the  localized  peritonitis  soon  becomes  generalized. 
Here  again  is  seen  a  resemblance  to  an  attack  of  appendicitis  with 
abscess  formation;  but  the  difference  in  the  shape  and  the  elasticity 
of  the  swelling,  the  slow  growth  preceding  the  sudden  onset,  the 
difference  in  the  character  of  the  pain  and  tenderness,  and  the  more 
general  rigidity  of  the  abdominal  wall  should  enable  one  to  dis- 
tinguish between  these  affections.  If,  however,  for  any  reason  it  be 
impossible  to  make  a  differential  diagnosis,  I  would  advise  that  at 
operation  the  lateral  incision  be  the  one  chosen,  because  appendi- 
citis is  so  much  more  common  an  affection  that  the  chances  are  in 
favor  of  its  being  the  cause  of  the  symptoms.  The  median  incision 
for  appendicitis  is  illogical,  unwise,  and  will  in  many  instances 
hinder,  if  not  entirely  prevent,  the  proper  treatment  of  the  appendix. 
Even  through  the  ordinary  incision  the  removal  of  an  adherent 
appendix  from  behind  the  caecum  may  be  extremely  difficult;  and 
through  a  median  incision  it  often  will  be  impossible.  These 
difficulties  are  generally  increased  when  there  is  pus  formation, 
and  under  such  circumstances  any  other  than  the  lateral  incision 
usually  multiplies  the  danger  of  peritoneal  infection. 

Torsion  of  the  omentum  when  it  occurs  acutely  may  give  rise 
to  pain,  vomiting  and  extreme  tenderness  accompanied  by  the  for- 
mation of  a  mass.  If  this  be  in  the  neighborhood  of  the  appendix 
it  is  difficult  to  escape  diagnosis  of  appendicitis  with  periappendic- 
ular involvement.  In  general  the  systemic  symptoms  of  infection 
and  toxaemia  are  less  marked  than  in  appendicitis  though  after 
gangrene  has  set  in,  which  may  occur  early,  fever  and  leucocytosis 
occur  Just  as  in  appendicitis. 

PNEUMONIA  AND  PLEURITIS. 

The  onset  in  these  two  diseases  is  sometimes  very  acute,  and 
the  pain  in  the  side  may  be  so  severe  as  to  cause  rigidity  of  the 
abdominal  muscles  on  the  side  affected.  If  this  be  the  right,  the 
diagnosis  is  sometimes  quite  difficult,  especially  in  children,  who 
are  unable  to  describe  their  pain  accurately.  In  pneumonia, 
however,  the  predisposing  cause  is  more  often  exposure  to  inclem- 


248  Appendicitis 

ent  weather,  a  preliminary  chill  is  frequent,  vomiting  is  less  usual, 
there  is  cough,  and  the  pain  is  probably  never  limited  to  the  ab- 
domen; while  in  appendicitis  there  has  usually  been  some  indiges- 
tible food  eaten,  a  chill  is  very  unusual,  vomiting  is  the  rule,  and  the 
pain  is  generally  umbilical  at  first,  later  settling  to  the  right  iliac 
fossa.  There  is  seldom  in  appendicitis  any  thoracic  pain,  nor  a 
cough.  Physical  examination  will  usually  clear  up  any  doubt  by 
the  revelation  of  the  pathognomonic  subcrepitant  rale  at  the  end  of 
inspiration  in  pneumonia,  or  by  the  friction  sound  in  pleurisy.  In 
pulmonary  disease  the  abdominal  rigidity  is  easily  overcome  and 
the  tenderness  is  not  marked,  if  palpation  be  done  with  the  palm 
of  the  hand  rather  than  the  finger  tips.  Guinou  insists  upon  this 
means  of  differentiating  the  two  affections,  having  found  that  deep 
but  gentle  pressure  with  the  palm  of  the  hand  caused  a  cessation 
of  the  pain  at  McBurney's  point  if  the  affection  was  thoracic. 

Brewer  has  recorded  the  case  of  a  patient  who,  having  had 
several  attacks  of  appendicitis,  complained,  when  recovering  from 
a  pneumonia,  of  sudden  pain  "  in  the  right  inguinal  region."  Symp- 
toms of  general  peritonitis  followed;  the  precarious  condition  of  the 
patient  forbade  any  operation.  At  the  autopsy  not  a  trace  of 
abdominal  inflammation  was  found,  but  cultures  from  the  heart  and 
spleen,  showing  the  pneumococcus,  proved  it  to  be  a  case  of  pneu- 
mococcic  septicaemia. 

INTUSSUSCEPTION  OF  THE  APPENDIX. 

The  causes  of  this  affection,  like  those  of  intussusception  in 
general,  are  very  obscure.  In  some  cases,  notably  Rolleston's, 
a  concretion  within  the  appendix  has  seemed  to  excite  such  violent 
peristalsis  as  to  cause  prolapse  of  part  or  all  of  the  appendix  into 
the  caecum.  In  Rolleston's  patient,  who  died  from  perforation  of  a 
duodenal  ulcer,  without  operation,  only  the  mucous  membrane  of 
the  appendix  was  found  prolapsed  into  the  caecum,  a  coprolith  being 
impacted  in  its  orifice.  It  is  of  course  probable  that  when  partial 
inversion  has  occurred  the  protruding  portion  acts  as  a  polyp  does  in 
irritating  the  rectum  or  the  uterus,  or  like  an  elongated  uvula,  as 
suggested  by  Corner,  in  irritating  the  pharynx  to  renewed  contrac- 
tions.    In  no  case  were  there  evidences  of  previous  attacks  of  appen- 


Differential  Diagnosis  249 

dicitis.  Indeed,  as  remarked  by  Battle  and  Corner,  it  seems  reason- 
able to  suppose  that  previous  attacks  of  inflammation  would  have 
rendered  the  appendix  less  liable  to  become  intussuscepted,  both 
by  the  stiff  and  unyielding  condition  of  its  walls  thus  induced,  and 
by  the  production  of  peri-appendicular  adhesions.  Abnormal 
length  of  the  mesentery  and  the  ascending  meso-colon  is  considered 
by  some  a  predisposing  cause  of  appendicular  intussusception. 
Two  patients  had  tuberculous  disease  of  the  peritoneum. 

The  treatment,  therefore,  to  be  advised  for  these  cases,  consists 
of  laparotomy  and  gentle  attempts  at  reduction,  and  if  these  fail, 
of  excision  of  the  appendix  and  so  much  of  the  csecum  and  ileum 
as  shall  be  found  to  be  irreducible.  The  appendix  should  always 
be  removed,  to  prevent  a  recurrence  of  the  trouble. 


250  Appendicitis 


FIG.  13. 

Case  of  Dr.  Thomas  R.  Neilson. — Invagination  of  Appendix. — G.  B.,  a 
little  girl  of  five  years  of  age,  admitted  to  St.  Christopher's  Hospital,  under  Dr.  Neilson's 
care,  December  26,  1903.  Four  days  previously  the  child  had  been  attacked  with 
severe  abdominal  pain  causing  her  to  crouch  down  on  the  floor,  scream,  double  up  and 
hold  her  abdomen  tightly  with  her  hands.  This  attack  was  followed  by  pallor,  and 
the  child  seemed  greatly  fatigued.  On  the  night  of  the  25th  the  attacks  became  more 
frequent,  recurring  at  short  intervals.  There  was  no  nausea  or  vomiting  at  any  time; 
the  bowels  moved  very  frequently,  the  stools  being  small.  Examination  revealed  only 
very  slight  rigidity  of  the  lower  segment  of  the  right  rectus  muscle;  there  was  no 
tympany;  there  was  slight  tenderness  in  the  region  of  the  appendix. 

Dr.  Neilson's  diagnosis,  accordingly,  was  chronic  appendicitis  with  adhesions. 

Operation  by  Dr.  Neilson  Januarj'  i,  1904:  The  appendix  was  found  invaginated 
into  itself  and  into  the  caecum  for  upwards  of  one  inch.  There  was  no  evidence  of 
any  other  pathological  condition  thereabouts.  The  drawing  on  the  opposite  page 
accurately  illustrates  the  condition  found.  The  mucosa  of  the  Ccccum  surrounding 
the  intussusception  was  markedly  congested. 

An  attempt  was  made  first  to  draw  out  the  intussuscepted  portion  of  the  appendix, 
but  this  failed,  and  accordingly  the  whole  mass  was  excised  from  the  cascum  and  the 
opening  closed  by  ordinary  methods. 

The  child  made  a  complete  and  uneventful  recovery. 


Differential  Diagnosis 


251 


Fig.  13. — Intussusception  of  the  Appendix. 
From  a  patient  under  the  care  of  Dr.  Neilson. 


THE  BLOOD  IN  APPENDICITIS. 

Appendicitis  shares  with  other  acute  infections  the  property 
of  causing  an  increase  in  the  number  of  leucocytes  in  the  circu- 
lating blood.  This  characteristic  gives  in  some  cases  material 
aid  in  diagnosis  where  the  question  is  between  appendicitis  and 
some  other  painful  abdominal  condition  which  is  not  commonly 
accompanied  by  leucocytosis,  as  examples  of  which  may  be  men- 
tioned movable  kidney,  stone  in  the  ureter,  and  typhoid  fever. 

The  standard  which  we  have  chosen  as  the  normal  number  of 
leucocytes  is  7500  per  cubic  millimetre.  Variations  need  not  be 
given  much  weight  either  as  a  leucocytosis  or  as  a  leucopenia  until 
the  number  rises  above  10,000  or  falls  below  5000.  Roughly  speak- 
ing also,  the  degree  of  rise  in  the  white  cells  is  proportionate  to  the 
absorption  into  the  systemic  circulation  of  the  toxins  generated  by 
the  infection.  Formerly  there  was  a  disposition  to  make  this 
property  an  index  of  the  severity  of  the  appendicular  disease  and 
therefore  of  the  necessity  for  immediate  operation.  The  fallacy 
of  this  attempt  has  been  demonstrated  by  increasing  experience 
and  is  due  largely  to  two  reasons,  (i)  Infection  of  sudden  over- 
whelming severity  may  be  accompanied  by  no  rise  in  the  leucocyte 
count.  At  times  there  may  even  be  a  diminution  (leucopenia). 
The  reason  for  this  appears  to  be  the  fact  that  leucocytosis  is  an 
expression  not  only  of  infection  but  also  of  the  resistance  of  the 
individual  attacked.  When  the  patient  is  overwhelmed  the  func- 
tion of  leucocyte  production  shares  in  the  general  depression  and 
the  white  cells  which  appear  in  the  circulating  blood  are  withdrawn 
into  the  immediate  vicinity  of  the  infection  with  equal  or  greater 
rapidity  than  they  can  be  produced.  Fortunately  this  state  of 
affairs  is  not  common,  yet  it  is  seen  sufficiently  often  to  compel 
attention.  Usually  the  patient  thus  affected  is  one  who  has  been 
weakened  by  age,  excesses  or  chronic  disease. 

(2)  The  absorption  of  toxins  does  not  in  many  instances  run 
parallel  with  the  appendiceal  lesion.  It  is  not  uncommon  to  find 
the  leucocytosis  in  acute  catarrhal  or  interstitial  appendicitis  run 

252 


The  Blood  in  Appendicitis  253 

higher  than  when  the  organ  has  become  completely  gangrenous. 
This  is  not  surprising  when  we  consider  that  in  gangrene  of  the 
appendix  the  efferent  veins  and  lymphatics  may  be  completely 
thrombosed  thus  cutting  off  the  infected  area  from  the  general 
circulation.  This  failure  of  the  toxins  to  be  absorbed  is  probably 
responsible  also  for  the  well-known  clinical  observation  that  the 
temperature  is  apt  to  be  but  little  elevated  when  the  appendix 
undergoes  gangrene.  Not  only  is  it  true  that  the  more  severe 
manifestations  of  the  disease  may  give  lower  leucocyte  counts 
but  the  same  variety  of  appendicitis  so  far  as  its  clinical  course 
is  concerned  may  give  greatly  varying  degrees  of  leucocytosis  as 
the  appended  table  shows  at  a  glance.  It  is  more  than  probable 
that  different  types  of  infection  will  exercise  greatly  differing  powers 
of  chemotaxis  upon  which  the  leucocytic  response  depends.  There 
has  been  no  attempt  made  to  correlate  leucocytosis  with  the  type 
of  appendiceal  infection,  and  even  were  the  laws  governing  it  known 
to  us  it  would  be  of  no  practical  value  from  a  prognostic  standpoint 
since  it  is  manifestly  impossible  to  determine  the  nature  of  the  infec- 
tion without  operation  and  then  only  after  an  interval  required  by 
the  bacteriological  technic. 

Chronic  appendicitis  unless  in  the  presence  of  a  more  or  less 
acute  exacerbation  does  not  disturb  the  absolute  or  relative  number 
of  the  leucocytes. 

The  variability  of  the  leucocyte  count  and  the  elusive  nature  of 
the  factors  which  control  it  are  such  as  to  make  the  estimation  of 
the  leucocytes  a  very  unreliable  guide  in  both  diagnosis  and  prog- 
nosis. It  is  by  no  means  a  cardinal  symptom  to  be  considered  with 
the  diagnostic  triad  of  pain,  vomiting  and  local  tenderness.  When 
used  as  a  guide  for  treatment  too  much  reliance  in  it  can  result  only 
in  catastrophe.  If  it  be  used  as  a  subsidiary  aid  and  its  limitations 
understood  it  is  of  value  and  should  be  obtained  as  routinely  as  the 
history  and  physical  examination,  but  I  must  emphasize  the  state- 
ment that  operation  must  never  be  undertaken  nor  deferred  on  the 
basis  of  the  leucocyte  count  alone. 

Differential  Leucocyte  Count. — During  the  last  few  years  the 
importance  of  the  differential  count  has  been  urged  by  some  as 
of  value  in  supplementing  the  information  obtained  from  the  simple 
estimation  of  the  number  of  cells.     This  consists  in  the  determina- 


254  Appendicitis 

tion  of  the  percentages  of  the  various  kinds  of  leucocytes  as  seen  in 
the  appropriately  stained  preparation.  It  is  well  known  that  the 
leucocytosis  which  is  due  to  pyogenic  infections  is  accompanied  by 
a  greater  relative  increase  of  the  polymorphonuclear  neutrophilic 
leucocytes  than  of  the  other  varieties  of  leucocytes.  Normally 
the  polymorphonuclears  comprise  about  70  per  cent,  of  the  total 
number  of  leucocytes.  These  are  the  cells  which  are  chiefly  con- 
cerned in  suppuration  and  as  found  in  pus  are  known  as  pus  cor- 
puscles. Evidently  the  chemotactic  power  of  pyogenic  toxins  is 
exerted  more  strongly  upon  these  cells  than  upon  the  other  white 
corpuscles  of  the  blood.  It  has  been  claimed  therefore  that  their 
behavior  affords  an  index  as  to  the  severity  of  the  infection.  Stated 
in  general  terms  the  leucocyte  count  is  an  index  of  the  resistance 
of  the  patient,  the  polymorphonuclear  percentage  indicates  the 
severity  of  the  toxaemia.  In  my  clinic  we  have  the  differential 
count  made  as  routinely  as  the  simple  count  and  have  now  more 
than  a  thousand  observations  of  the  behavior  of  the  polymorpho- 
nuclear cells  in  acute  and  chronic  appendicitis.  In  general  I  can 
corroborate  the  statement  that  a  high  proportion  of  polymorpho- 
nuclears is  significant  of  a  severe  infection  and  when  coupled  with 
little  or  no  rise  in  the  absolute  number  of  leucocytes  it  is  a  bad  sign. 
Yet  I  have  never  decided  for  or  against  operation  on  the  evidence  of 
the  leucocyte  count  alone  and  have  frequently  seen  satisfactory 
recoveries  in  cases  that  showed  from  90  to  96  per  cent,  of  poly- 
morphonuclears. Murphy  quotes  Albrecht's  views  on  the  differ- 
ential count  as  coinciding  with  his  opinions  and  his  conclusions  are 
those  which  I  also  have  reached.  Murphy  says  "The  percentage 
of  polynuclear  cells  is  an  indication  of  the  severity  of  the  infection, 
but  not  the  degree  of  destruction.  A  high  percentage  does  not 
denote  a  bad  prognosis,  so  long  as  the  absolute  number  of  white 
cells  is  correspondingly  high.  A  fall  in  the  absolute  number  of 
polynuclears  with  a  coincident  decrease  of  the  total  percentage  of 
leucocytes  shows  a  decline  in  the  infection." 

Such  a  conservative  estimate  of  the  value  of  the  differential 
count  is  more  nearly  correct  than  the  emphasis  laid  upon  it  by 
Noehren  who  considers  the  estimation  of  the  polymorphonuclears 
alone  as  of  greater  importance  than  the  absolute  white  cell  count 
or  the  relation  between  the  two.     He  also  attempts  to  use  the  poly- 


The  Blood  in  Appendicitis  255 

morphonuclear  count  as  an  indication  for  or  against  operation,  a 
misuse  of  a  minor  diagnostic  sign  which  is  pernicious,  dangerous 
and  which  I  unhesitatingly  condemn. 

Gibson  lays  stress  on  the  disproportionate  rise  of  the  polymor- 
phonuclear percentage  as  compared  with  the  leucocyte  count 
itself  and  considers  this  as  indicating  the  gravity  of  the  lesion.  In 
many  cases  this  is  tj^ue,  but  it  is  not  infallible.  A  rise  in  the  poly- 
morphonuclear percentage  with  a  stationary  leucocyte  count,  in 
the  presence  of  other  symptoms  of  continued  infection  may  be  an 
additional  sign  of  the  gravity  of  the  lesion. 

To  Determine  the  Extent  of  the  Lesion. — The  blood  count  is 
especially  deceptive  when  it  is  used  in  an  endeavor  to  determine 
the  extent  of  intra-  or  extra-appendicular  involvement.  In  a  very 
broad  way  the  leucocyte  count,  in  a  patient  previously  well  and  of 
good  resistance,  may  be  said  to  indicate  by  its  grade  the  severity  of 
the  disease  when  taken  in  conjunction  with  the  clinical  symptoms. 
Thus,  a  moderate  count  of  10-15,000  is  the  usual  accompaniment 
of  an  ordinary  catarrhal  or  interstitial  appendicitis  while  higher 
courfts  indicate  more  acute  changes  or  a  rapidly  developing  peri- 
toneal involvement.  There  are  so  many  varying  factors,  however, 
in  this — the  patient's  resistance,  the  kind  of  infection,  the  previous 
condition  of  the  appendix  and  its  anatomical  relations — that  it  is 
best  to  consider  it  but  very  slightly  in  determining  the  extent  of  the 
inflammatory  process.  Manifestly  it  can  give  us  no  information 
regarding  the  imminence  of  gangrene  or  perforation  which  are  the 
paramount  issues.  I  have  seen  very  mild  grades  of  appendicitis 
give  high  initial  leucocytosis,  and  the  reverse  also  holds  good. 
Finally,  decision  as  to  the  advisability  of  operation  in  this  disease  in 
which  time  is  such  a  precious  consideration  should  never  be  delayed 
for  successive  leucocyte  counts  or  differential  estimations  since  the 
surgeon  will  soon  find  that  the  relationship  of  the  laboratory  findings 
to  the  clinical  necessities  is  so  variable  that  in  the  very  cases  where 
he  most  needs  help  there  it  will  be  too  often  lacking.  There  can 
be  no  objection  to  following  the  leucocytes  in  the  cases  that  are  not 
suitable  for  immediate  operation  but  in  these  cases  also  it  will  be 
found  that  the  proper  moment  for  operation  is  to  be  determined  by 
other  considerations  than  the  leucocytes. 

The  appended  table  will  show  according  to  groups  the  actual 


256 


Appendicitis 


initial  count  in  my  last  1018  cases  of  acute  appendicitis  in  which 
a  blood  count  was  made. 


Leucocytes  Catarrhal      Purulent 


25,000  and  over. 


Gan-         Localized 
grenous         abscess 


Slight 

free 

fluid 


306 


127 


66 


307 


78 


Diffuse 

and 
general 


i 

d. 

g- 

5,oco-io,ooo.. .  . 

153 

44 

10 

67 

II 

15 

IS 

10,000-15,000.. .  . 

105 

50 

23 

120 

I       31 

,38 

IS 

15,000-25,000.. .  . 

46 

28 

31 

108 

30 

36 

8 

4       3 


93     41 


* 

Up  to 
10,000 

10,000- 

15,000 

15,000- 

25,000 

25,000 
and  plus 

Totals 

Catarrhal 

I  S3 

loS 

46 

2 

306 

Purulent . .  . 

44 

50 

28 

5 

127 

Gangrene. . 

10 

23 

31 

2 

66 

Localized  abscess. . . 

67 

120 

108 

12 

307 

Slight  free  fluid .... 

II 

31 

30 

6 

78 

Diffuse  and 

general . 

.(d) 
(g) 

IS 
IS 

38 
IS 

36 

8 

4 
3 

93 
41 

To  Determine  the  Prognosis. — ^The  salient  feature  of  the 
value  of  the  blood  count  in  prognosis  is  the  fact  that  a  low  count  in 
the  presence  of  grave  symptoms  and  evidences  of  peritonitis  is  a 
danger  signal.  This  combination  of  symptoms  might  possibly  lead 
us  to  delay  operation  in  a  given  case,  trusting  to  the  patient's  recu- 
perative powers  under  proper  medical  treatment  rather  than  risking 
surgical  intervention  when  the  resistance  is  so  far  lowered.     Other- 


The  Blood  in  Appendicitis  257 

wise  the  leucocyte  count  is  valueless  in  prognosis  and  entirely  so  as 
an  indication  for  or  against  operation. 

The  iodine  reaction  is  of  no  value  in  appendicitis.  As  a  means 
of  determining  the  presence  of  toxaemia  it  is  inferior  to  the  leucocyte 
count  or  a  polymorphonuclear  increase,  with  which  it  corresponds 
in  significance  and  generally  in  occurrence.  It  is  found  in  so  many 
diseases  and  is  so  uncertain  in  technic  that  it  has  fallen  into  well- 
merited  disrepute. 


17 


PROGNOSIS. 

The  prognosis  in  a  given  case  of  appendicitis  has  reference, 
first,  to  the  attack  from  which  the  patient  may  at  the  moment  be 
suffering,  and,  secondly,  to  the  future  health  of  the  patient.  There 
can  be  no  question  that  under  all  circumstances  appendicitis  is  a  most 
serious  disease.  It  resembles  certain  other  diseases — typhoid  fever, 
for  instance — in  that  at  the  time  of  examination  of  the  patient  the 
local  and  general  conditions  may  be  such  that  the  unwary  would 
give  a  favorable  prognosis,  whereas  the  judicious  and  conservative 
physician  or  surgeon,  from  his  knowledge  of  the  morbid  processes 
at  work,  states  that  the  present  condition  of  the  patient  is  favorable, 
but  at  the  same  time  frankly  acknowledges  his  inability  to  foretell 
what  may  occur  within  the  coming  hour.  An  attack  of  typhoid 
fever  may  be  pursuing  a  favorable  course  until,  entirely  unannounced, 
intestinal  haemorrhage  or  perforation  occurs  and  completely  alters 
the  aspect  of  the  case.  Similarly,  a  patient  suffering  with  appen- 
dicitis may  be  progressing  favorably,  when  suddenly  gangrene  or 
perforation  of  the  appendix  or  rupture  of  a  circumscribed  peri- 
appendicular abscess  may  occur,  and  his  condition  may  become 
most  serious. 

With  reference  to  the  attack  of  appendicitis  from  which  the 
patient  may  at  the  moment  be  suffering,  it  is  doubtless  true  of  appen- 
dicitis, as  of  other  diseases,  that  a  certain  proportion  of  cases  will 
do  well  and  ultimately  recover  under  any  treatment  dictated  by 
reason  and  the  requirements  of  hygiene.  It  is  claimed  that  from 
80  to  90  percent,  of  all  cases  will  recover  under  medicinal,  as  opposed 
to  surgical,  treatment.  But  too  frequently  I  have  seen  patients  who 
were  apparently  recovering,  or  who  were  accounted  as  having  al- 
ready recovered,  suddenly  lapse  into  a  critical  condition,  and  some- 
times die  in  spite  of  the  most  heroic  measures  to  prolong  their  lives. 
The  reason  for  this  sudden  change,  and  the  possibility  of  its  occur- 
ring at  any  moment,  must  be  evident  to  all  who  have  the  slightest 
acquaintance  with  the  pathology  of  appendicitis.  The  likelihood 
of  the  subsidence  of  the  inflammatory  phenomena  in  an  appendix 

258 


Prognosis  259 

and  of  the  return  of  the  organ  to  a  healthy  condition  decreases, 
moreover,  with  the  increase  in  the  number  and  severity  of  the  attacks. 
The  reasons  for  this  will  be  evident  to  those  who  read  the  chapter 
on  the  Pathology  of  the  affection. 

Specifically,  the  prognosis  in  many  of  the  cases  that  are  charac- 
terized clinically  as  mild,  in  which  there  is  no  demonstrable  tumor, 
but  little  tenderness,  and  slight  fever,  and  in  which  the  lesions  are 
probably  catarrhal  or  a  minor  grade  of  interstitial  alterations,  is 
good  with  reference  to  the  subsequent  health  of  the  patient.  The 
prognosis  with  reference  to  the  recovery  from  the  attacks  is  good  only 
with  the  important  reservations  that  it  becomes  progressively  worse 
with  each  succeeding  attack,  and  that  we  are  unable  to  state  at 
what  moment  the  pathological  alterations  may  become  much  ag- 
gravated, and  perforation  or  gangrene  of  the  appendix  ensue.  Then 
it  must  also  be  borne  in  mind  that  relatively  mild  clinical  mani- 
festations may  be  associated  with  serious  anatomical  lesions, 
and  that  from  the  presence  of  the  former  we  are  not  warranted 
in  assuming  the  absence  of  the  latter.  The  prognosis  as  to  re- 
covery from  the  attack  is  good,  particularly  in  those  of  this  class 
of  cases  in  which  a  rapid  amelioration  of  symptoms  follows  the 
institution  of  rational  medical  treatment.  These  cases  often  ter- 
minate favorably  without  recourse  to  operative  measures,  but  the 
appendix  remains  in  a  diseased  condition,  and  is  liable  at  any  time 
to  develop  most  acute  exacerbations  of  inflammation,  with  all  their 
attendant  dangers.  The  general  health  of  the  patient,  moreover, 
cannot  be  considered  a  reliable  guide  in  the  question  of  prognosis; 
the  robust  and  healthy  are  quite  as  liable  to  develop  unfavorable 
symptoms  as  are  the  weakly  and  ill-developed.  But  age  and  sex 
have  some  bearing  upon  prognosis,  although  their  importance 
is  often  exaggerated;  children  and  females  have  in  my  experience 
been  more  fortunate  in  recovering  from  appendicitis  than  have 
adult  males. 

Those  cases  that  present  evidences  of  suppuration  or  cellular 
infiltration  are  next  in  severity  to  those  characterized  clinically  as 
mild  cases,  where  no  tumor  can  be  detected.  These  cases  with  de- 
monstrable tumor,  marked  tenderness  and  rigidity  of  the  abdominal 
muscles  are  always  most  grave;  and  the  careful  physician  or  surgeon 
is  always  most  cautious  in  his  prognosis  where  such  symptoms  exist. 


26o  Appendicitis 

In  most  of  these  cases  we  are  warranted  in  assuming  the  presence  of 
pus,  but  we  are  unable  to  state  whether  the  appendix  is  perforated  or 
gangrenous,  whether  rupture  of  a  peri-appendicular  abscess  into 
the  general  peritoneal  cavity  or  into  the  intestine  or  other  intra- 
abdominal organ  is  imminent,  or  whether  erosion  and  necrosis,  or 
thrombosis  of  one  of  the  iliac  vessels  is  developing,  etc.  Such  is 
the  serious  import  of  these  conditions,  concerning  which  we  can 
state  nothing  definitely,  that  the  prognosis,  under  such  circum- 
stances, is  at  most  a  mere  hazard. 

Such  being  the  condition  of  affairs,  it  is  evident  that  the  prognosis 
in  a  given  case  of  appendicitis  depends  more  upon  the  form  of  treat- 
ment instituted  at  the  onset  than  upon  any  other  factor.  If  the 
appendix  be  skillfully  removed  within  twenty-four  hours  from  the 
commencement  of  the  attack,  the  prognosis  is  favorable,  and  re- 
covery will  ensue  in  all  but  the  most  exceptional  cases.  As  will  be 
seen  in  the  chapter  on  the  Treatment  of  appendicitis,  the  mortality 
from  this  disease  itself,  before  peritoneal  complications  have  de- 
veloped is,  when  treated  by  removal  of  the  appendix,  less  than  i  per 
cent.  This  gives  therefore  a  very  much  better  prognosis  both  as  to 
immediate  and  as  to  ultimate  recovery  than  does  any  other  form  of 
treatment.  It  is,  however,  undeniable  that  a  few  cases  will  recover 
from  their  first  acute  attack  without  operation,  and  that  a  small 
percentage  of  these  few  cases  may  have  no  return  of  symptoms.  As 
has  been  repeatedly  urged  in  these  pages,  the  surgeon  cannot  usually 
tell  from  the  symptoms  whether  a  case  is  progressing  favorably  or 
not;  and  in  those  apparently  mild  cases  where  it  seems  evident  that 
the  progress  is  favorable,  he  cannot  be  sure  that  perforation  or 
gangrene  will  not  occur  without  warning  in  the  course  of  the  next 
hour  or  two.  This  uncertainty  is  particularly  present  in  cases  where 
the  opium  treatment  is  adopted.  Such  is  the  apparent  ameliora- 
tion of  symptoms  that  follows  the  use  of  this  drug  that  the  surgeon 
is  often  led  to  infer  that  the  progress  of  the  disease  has  been  checked 
or  that  recovery  has  resulted.  In  many  of  these  patients,  however, 
despite  the  abeyance  of  symptoms,  the  disease  is  steadily  progressing, 
and  the  physician's  attention  is  finally  attracted  to  the  serious  con- 
dition of  the  partly  narcotized  patient  by  the  distended  and  tym- 
panitic abdomen,  the  "leaky"  skin,  and  the  rapid,  irregular  and 
weak  pulse. 


Prognosis  261 

The  prognosis  is  materially  influenced  by  the  conditions  found 
at  operation.  These  are  discussed  at  considerable  length  in  the 
chapter  on  the  Complications  and  Sequels  of  Appendicitis,  under 
the  heading  of  Complications  of  the  Operation. 

If  the  appendix  is  but  slightly  altered,  and  there  is  only  a  small 
amount  of  serous  or  sero-fibrinous  exudate  about  the  appendix, 
the  outlook  is  most  favorable.  Patients  with  such  conditions  should 
not  die;  and  it  will  be  found  that  deaths  following  an  operation 
undertaken  at  this  stage  of  the  disease  are  as  a  rule  due  to  some 
extraneous  and  independent  cause,  such  as  croupous  pneumonia, 
pulmonary  or  cerebral   embolism,   or  other  unavoidable   disease. 

If  there  is  a  circumscribed  peri-appendicular  abscess,  shut  off 
from  the  general  peritoneal  cavity  by  a  firm  fibrinous  exudate,  no 
matter  whether  the  appendix  be  perforated  or  gangrenous,  the  prog- 
nosis, with  certain  reservations,  is  good.  These  reservations  have 
reference  to  the  kind  of  treatment  adopted  prior  to  the  operation,  to 
the  condition  of  the  patient  at  the  time  of  operation,  to  the  care  prac- 
tised in  the  administration  of  the  anaesthetic,  to  the  skill  exercised 
in  the  operative  manipulations,  to  the  thoroughness  with  which  all 
purulent  foci  are  evacuated,  together  with  the  preservation  of  the 
general  peritoneal  cavity  from  infection;  to  the  presence  in  the  patient 
of  other  diseases,  such  as  tuberculosis,  heart  disease,  nephritis,  etc.; 
to  the  character  of  the  drainage  established  and  that  of  the  after- 
treatment  adopted.  If  before  the  operation  the  patient  has  been 
either  weakened  through  excessive  purgation,  or  narcotized  with 
opiates,  his  general  condition  at  the  time  of  operation  will  usually  be 
such  that  the  outlook  is  grave.  Where  heart  disease  or  nephritis  is 
present  the  operative  risk  is  naturally  much  increased,  not  alone 
from  the  conditions  surrounding  the  appendix,  but  from  the  anaesthe- 
tic as  well;  and  where  tuberculosis  is  present,  even  if  no  active 
abdominal  form  of  the  disease  is  noted,  yet  the  tendency  toward 
prolonged  suppuration  and  at  times  the  formation  of  a  faecal  fistula 
is  marked. 

If  there  is  a  diffusing  peritonitis  of  whatever  variety,  the  out- 
look is  ominous.  Such  conditions  are  sometimes  found  that  it  can 
be  stated  with  positiveness  that  the  patient  will  certainly  succumb. 
In  some  rare  cases  the  inflammatory  process  is  of  such  a  fulminat- 
ing character  that  it  may  be  impossible  to  secure  the  services  of  a 


262  Appendicitis 

surgeon  sufficiently  early  to  prevent  a  fatal  termination.  In  some 
cases  it  seems  as  if  the  fatal  termination  was  inevitable  from  the 
outset,  and  that  no  matter  how  early  or  how  skillfully  an  operation 
had  been  performed,  it  would  not  have  availed  to  rescue  the  patient. 
Such  cases  are  exceptional. 

Presuming  that  a  patient  recovers  from  an  attack  of  acute 
appendicitis,  the  prognosis  with  regard  to  his  subsequent  health 
varies  with  a  number  of  circumstances.  The  chief  factor  to  be 
considered  is  whether  or  not  the  appendix  was  removed  at  the 
primary  attack.  Even  if  it  was  removed  it  does  not  follow  that 
the  patient  will  necessarily  be  free  from  all  further  abdominal 
trouble.  In  cases  operated  on  in  the  early  stages,  however,  the 
likelihood  of  the  formation  of  any  adhesions  sufficient  to  produce 
even  the  slightest  discomfort  is  quite  remote.  When  adhesions 
were  already  present  at  the  time  of  operation,  however,  the  case 
is  very  different.  In  my  experience  intestinal  obstruction  has 
occurred  in  nearly  2  per  cent,  of  the  cases,  at  some  time  or  other 
after  the  operation.  Where  the  appendix  has  not  been  removed 
during  or  immediately  subsequent  to  the  first  attack,  the  prognosis 
is  much  more  gloomy.  Nearly  80  per  cent,  of  my  cases  have  had 
more  than  one  attack  of  appendicitis,  and  while  there  are  some  cases 
in  which  each  successive  attack  becomes  milder  in  character,  yet 
a  large  majority  of  patients  sooner  or  later  are  compelled  to  undergo 
an  operation,  either  because  the  constantly  recurring  attacks  inca- 
pacitate them  for  work,  or  because  suppuration,  gangrene,  perfora- 
tion or  general  peritonitis  finally  supervenes,  A  few  patients  have 
a  mild  or  even  a  moderately  severe  attack,  recover,  and  never  have 
any  further  symptoms.  In  general  the  milder  the  primary  attack, 
the  more  is  the  likelihood  of  such  being  the  case,  but  this  is  by  no 
means  an  invariable  rule.  In  the  majority  of  cases  recurrences 
sooner  or  later  develop.  Most  of  these  occur  within  the  first  six 
months  after  the  first  attack;  there  are  fewer  within  the  succeeding 
six  months;  and  the  likelihood  of  recurrence  decreases  with  each 
succeeding  year.  Occasionally,  however,  a  recurrent  attack  is 
noted  after  an  interval  of  fifteen  or  twenty  years.  Multiple  recur- 
rences are  extremely  common,  and  such  is  the  natural  course  of  the 
disease  that  it  may  be  stated  that  an  appendix  once  the  seat  of 
inflammation  is  prone  to  be  again  affected.     As  it  is  impossible  to 


Prognosis  263 

presage  either  the  time  or  the  severity  of  the  recurrence,  a  diseased 
appendix  is  a  menace  to  Ufe  as  well  as  to  health  as  long  as  it  remains 
in  the  body.  If  the  danger  from  adhesions  is  present  even  after 
removal  of  an  appendix  during  the  first  attack  of  the  disease,  it  is 
evident  that  this  danger  is  very  much  increased  as  long  as  the 
appendix  remains  in  the  abdomen.  Adhesions  to  the  parietal 
peritoneum,  omentum,  caecum,  colon,  small  intestine,  bladder, 
pelvic  organs,  etc.,  may  occur  and  give  rise  to  a  diversity  of  dis- 
tressing symptoms,  and  these  adhesions  when  firm  and  of  long  stand- 
ing necessarily  complicate  the  secondary  operation  and  render  the 
prognosis  more  unfavorable.  In  general  it  may  be  stated  that  the 
milder  grades  of  appendicitis  which  subside  with  the  formation  of 
extensive  adhesions  exert  more  of  an  influence  upon  the  prognosis 
than  those  cases  of  suppurative  appendicitis  in  which  the  abscess 
ruptures  spontaneously  into  the  bowel  or  where  the  operation  has 
been  limited  to  the  extra-peritoneal  evacuation  of  such  pus  collec- 
tion. The  latter  group  of  cases  does  not  cause  symptoms  referable 
to  the  appendix  region,  nor  do  the  lesions  recur  with  nearly  the  same 
frequency  as  those  with  extensive  adhesions.  In  some  of  these 
fulminating  cases  it  is  possible  that  the  appendix  is  destroyed  by 
the  intensity  of  the  primary  inflammation,  and  that  this  fact  ex- 
plains the  subsequent  freedom  from  recurrence. 


TREATMENT. 

The  treatment  of  both  acute  and  chronic  appendicitis  includes, 
in  its  widest  sense,  the  surgical  treatment,  such  non-operative  or 
medical  treatment  as  may  be  given  either  preliminary  to  operation 
or  throughout  the  course  of  the  disease  in  the  few  cases  not  suited 
for  operation  and  the  proper  hygiene  of  the  patient  between  attacks, 
should  he  be  allowed  to  have  more  than  one  attack.  We  should 
always  bear  in  mind,  however,  that  any  form  of  treatment  other 
than  the  surgical  is  to  be  considered  only  because  extraneous  con- 
ditions or  certain  definite  contraindications,  local  or  general,  render 
it  necessary  to  abandon  or  defer  operative  interference. 

Acute  appendicitis  is  the  absolute  domain  of  the  surgeon.  In 
America  at  least  it  is  the  consensus  of  opinion  among  both  surgeons 
and  internists  that  the  diagnosis  of  the  disease  furnishes  the  indica- 
tion for  operation.  Not  any  particular  severity  of  the  attack, 
grouping  of  symptoms,  or  special  local  signs  need  be  looked  for. 
Unless  there  are  present  one  or  more  of  the  very  few  conditions 
which  contraindicate  operation  it  should  be  performed,  and  as  a 
rule  at  the  very  earliest  possible  moment.  It  is  essential  that  this 
should  be  appreciated  fully  by  the  general  practitioner  as  it  is  he 
who  as  a  rule  first  sees  the  patient  and  upon  his  advice  operation  is 
undertaken  or  deferred.  It  is  but  rarely  that  a  patient  will  refuse 
operation  if  the  facts  and  the  dangers  of  delay  are  properly  presented 
to  him. 

It  has  been  abundantly  demonstrated  not  only  that  no  form  of 
medical  treatment  yet  devised  can  avert  a  fatal  outcome  in  a  con- 
siderable percentage  of  cases  of  acute  appendicitis,  but  also  that, 
granted  a  recovery  from  a  single  attack,  no  dietetic  or  hygienic 
regimen  can  guarantee  against  subsequent  acute  attacks  in  the 
majority  of  instances  nor  can  it  alleviate  the  various  disturbances 
which  are  consequent  upon  the  chronic  form  of  appendicitis. 

On  the  contrary  all  of  these  objects  can'  be  attained  with  a 
mortality  that  has  actually  reached  the  vanishing  point  when  the 
appendix  is  removed  sufficiently  early  in  the  disease.     There  is  no 

264 


Treatment  265 

logical  escape  from  the  principle  of  immediate  operation  in  acute 
appendicitis.  This  is  not  simply  a  reasoned  conclusion  but  one 
based  upon  a  personal  experience  now  comprising  many  thousand 
cases.  If  it  were  in  any  way  possible  to  determine  which  cases 
would  recover  and  which  get  worse  without  operation,  there  might 
be  some  ground  for  declining  to  advise  operation  in  every  case. 
But  such  a  distinction  is  entirely  impossible.  Cases  apparently 
mild  in  onset,  or  with  temporary  remissions  in  symptoms  are  but 
too  often  just  as  dangerous  as  those  apparently  more  severe.  We 
have  already  spoken,  in  the  chapter  upon  Symptomatology,  of  the 
practical  impossibility  of  determining  accurately  the  extent  of  the 
intra-appendiceal  lesion  by  either  the  history  of  the  attack  or  the 
physical  examination.  Nor  will  laboratory  methods  of  investiga- 
tion, such  as  the  leucocyte  count,  be  of  any  aid  to  us  in  this  connec- 
tion. This  fact  alone,  that  we  are  unable  to  prognosticate  the 
course  of  acute  appendicitis  from  its  symptoms,  should  be  sufficient 
to  lead  us  to  discard  any  method  of  treatment  which  seeks  to  dis- 
pense with  operation.  The  only  exceptions  to  the  application  of 
the  rule  of  immediate  operation  are,  first,  the  absence  of  a  competent 
surgeon  or  lack  of  the  essential  requirements  of  successful  surgery. 
There  are  few  places  in  the  civilized  world  to-day  where  this  may 
be  urged  as  a  valid  excuse.  Secondly,  the  inability  of  the  patient 
to  endure  any  surgical  procedure  with  a  reasonable  certainty  of 
success.  Such  cases  are  few  and  depend  upon  the  existence  of  a 
severe  organic  disease  which  would  contraindicate  surgical  treat- 
ment of  any  kind.  No  one  who  is  not  identified  with  surgery  should 
presume  alone  to  pass  upon  such  a  matter.  The  obligation  of  the 
physician  to  secure  a  surgical  opinion  in  these  cases  is  equally  great 
if  not  greater  than  in  cases  which  are  not  thus  complicated. 

It  is  but  a  short  time  since  a  cardiac  murmur  was  considered 
almost  an  absolute  bar  to  operation.  We  now  know  that  the  true 
criterion  of  the  ability  of  the  heart  to  endure  the  strain  of  anaes- 
thesia and  operation  is  not  its  anatomical  or  pathological  peculiari- 
ties but  its  functional  capability.  A  heart  which  is  not  in  a  state  of 
broken  compensation  can  readily  endure  the  short  anaesthesia  and 
slight  trauma  incident  to  the  removal  of  the  appendix  by  a  skillful 
operator  w^hen  complications  are  absent.  In  these  cases  there  is 
even  greater  peril  in  delay.     It  cannot  be  too  strongly  urged  that 


266  Appendicitis 

cardiac  murmurs,  arrhythmia  or  hypertrophy  are  no  bar  to  opera- 
tion when  the  heart  is  able  to  carry  on  its  circulatory  function  in  a 
satisfactory  manner.  The  same  principle  applies  to  renal  and 
pulmonary  complications.  As  a  rule,  also,  it  is  possible  for  a  skill- 
ful anaesthetist  to  give  ether  to  these  patients  with  safety.  In  a 
very  few  cases  chloroform  or  nitrous  oxide  and  oxygen  may  seem 
to  possess  an  advantage  and  when  general  anaesthesia  is  considered 
out  of  the  question  we  still  have  at  our  disposal  intraspinal  or  one 
of  the  methods  of  local  anaesthesia. 

With  the  acceptance  of  the  above  principles,  under  ideal  con- 
ditions there  would  be  no  need  for  further  discussion  of  treatment 
except  from  the  purely  operative  standpoint.  Unfortunately 
owing  to  external  conditions,  to  delay  on  the  part  of  the  patient 
or  his  physician,  too  often  I  regret  to  say  the  latter,  or  to  an  unusual 
variation  or  rapidity  of  the  disease  process  we  are  obliged  to  con- 
sider what  is  often  the  most  difficult  aspect  of  the  problem,  namely: 

The  Time  for  Operation. — At  the  outset  of  this  discussion  we 
must  insist  that  this  is  purely  a  question  for  the  surgeon  to  decide. 
There  can  he  no  qualification  of  the  rule  that  the  surgeon  is  to  be 
summoned  by  the  physician  as  soon  as  the  diagnosis  is  made  and 
the  patient's  consent  obtained.  Within  the  first  few  hours  the  in- 
flammatory process  is  as  a  rule  confined  to  the  appendix  itself. 
Pathologically  this  may  be  considered  the  first  stage  of  the  disease. 
Clinically  it  is  the  optimum  time  and  condition  for  operation  and 
uniform  success  may  be  expected. 

The  second  stage  of  acute  appendicitis  comprises  those  cases  in 
which  the  inflammation  has  passed  beyond  the  confines  of  the  appen- 
dix itself  and  has  involved  the  adjacent  peritoneum  in  an  inflamma- 
tory process  which  becomes  either  a  localizing  or  a  diffusing  perit- 
onitis. In  the  most  favorable  form  of  localizing  peritonitis  the 
appendix  is  quickly  surrounded  by  fresh  adhesions  to  the  neighbor- 
ing viscera,  notably  the  omentum,  without  the  formation  of  pus 
outside  of  the  appendix,  a  condition  which  in  respect  to  surgical 
prognosis  is  happily  almost  as  favorable  as  that  in  which  the  process 
has  not  been  allowed  to  progress  beyond  the  appendix.  The  less 
favorable  and  more  frequent  form  of  localizing  peritonitis  results 
in  peri-appendicular  abscess.  The  diffusing  variety  of  inflammation 
tends  to  progress  to  general  peritonitis  and  death.     It  may,  however. 


Treatment  267 

be  checked  in  its  course  and  either  undergo  complete  resolution  or 
leave  in  its  wake  one  or  more  residual  abscesses  which  are  not  nec- 
essarily in  the  neighborhood  of  the  appendix. 

It  is  in  connection  with  the  diffusing  type  of  peritonitis  that  it 
becomes  necessary  to  decide  whether  or  not  immediate  operation 
will  necessarily  be  for  the  best  interests  of  the  patient.  In  acute 
appendicitis  we  may  find  very  early  a  slight  amount  of  fluid  in  the 
neighborhood  of  the  appendix.  Primarily  in  many  cases  the  serous 
exudation  from  an  inflamed  appendix  is  sterile  but  in  the  stage 
here  considered  it  contains  bacteria  and  presents  a  cloudy,  flaky  or 
purulent  appearance,  and  is  frequently  malodorous.  While  there 
is  as  yet  no  attempt  at  limitation  of  the  process  by  cohesion  of  the 
adjacent  coils  of  intestine  or  omentum,  still  the  process  in  its  extent 
is  a  limited  one.  The  clinical  signs  of  the  disease  are  correspond- 
ingly confined  to  the  location  of  the  appendix.  The  patient  also  does 
not  present  the  appearance  of  being  desperately  ill.  The  appendix 
may  be  acutely  inflamed,  or  recently  perforated  or  gangrenous.  It  is 
still  the  key  to  the  situation.  Remove  it,  prevent  it  from  pouring  out 
into  the  neighborhood  additional  infective  material  and  the  perit- 
oneum will  care  for  the  local  peritonitis  unless  the  infecting  agent 
be  exceptionally  virulent  or  the  resistance  unusually  low.  Success 
in  these  cases  will  be  almost  as  uniform  as  in  the  cases  where  the 
disease  is  entirely  intra-appendiceal.  Thus  far  the  treatment  may 
be  classed  practically  as  ideal.  Drainage  will  usually  be  unnec- 
essary or  at  least  may  be  limited  in  amount  and  brief  in  duration. 
The  patient  recovers  rapidly,  with  few  intra-abdominal  adhesions, 
with  little  liability  to  complications  and  possesses  a  strong  abdominal 
wall  after  healing  has  taken  place.  We  may  unhesitatingly  lay 
down  the  rule,  That  in  every  case  of  appendicitis  seen  early  opera- 
tion is  indicated  regardless  of  the  mildness  of  the  attack,  and  regardless 
of  the  severity  of  the  attack. 

If  the  appendix  is  not  removed  within  this  early  period  of  local 
disease  and  signs,  we  shall  encounter  an  increasing  number  of  cases 
with  advanced  progressing  peritonitis  who  are  evidently  desperately 
sick.  If  the  facies  Hippocratica  is  not  present  in  typical  form  it  is  at 
least  foreshadowed.  The  pulse  is  rapid,  soft  and  gaseous  in  charac- 
ter. The  skin  shows  capillary  stasis  or  a  faint  cyanosis.  Later  it 
may  become  leaky  and  pale.     The  temperature  is  usually  as  high 


268  Appendicitis 

as  102°  F.,  but  may  be  normal.  The  respiration  is  moderately  ac- 
celerated but  inclines  to  be  shallow  and  thoracic  in  type.  On  exam- 
ination the  whole  abdomen  is  tense.  Tenderness  and  spasm  while 
usually  most  marked  in  the  right  iliac  fossa,  are  not  infrequently  evi- 
dent upon  the  left  side  as  well  and  pressure  over  the  upper  abdomen 
is  also  resented.  At  first  distention  may  not  be  noticeable  though 
it  soon  becomes  apparent.  Peristalsis  is  retarded  and  brief  and  tink- 
ling in  character.  There  is  no  free  passage  of  flatus  or  faeces.  The 
leucocyte  count  is  usually  moderately  high  as  is  the  percentage  of 
polymorphonuclear  leucocytes.  The  lower  the  leucocytosis  and 
the  higher  the  percentage  of  polymorphonuclears  the  more  severe 
is  the  process  as  a  rule. 

In  such  a  case  we  may  expect  to  find  upon  opening  the  abdomen 
not  only  a  diseased  appendix  but  a  widespreading  peritonitis.  The 
coils  of  intestine  in  the  immediate  neighborhood  of  the  appendix 
may  or  may  not  show  beginning  cohesion.  In  any  event  it  is  evident 
that  the  peritoneal  inflammation  while  taking  its  origin  from  the 
appendix  is  no  longer  dependent  upon  it  for  its  existence.  Indeed, 
the  area  of  peritoneum  in  the  neighborhood  of  the  appendix  is 
usually  in  the  most  favorable  state  of  any  area  within  the  peritoneum 
so  far  as  its  systemic  affect  is  concerned.  Being  the  oldest  focus 
of  inflammation  it  shows  the  greatest  deposit  of  lymph.  The  most 
effectual  coffer-damming  against  infection  and  absorption  has  here 
been  done.  It  is  in  the  fresher  area  of  the  peritoneal  cavity  that 
the  real  conflict  is  being  waged,  that  exudation  of  immune  bodies 
and  cells,  and  absorption  of  bacteria  and  toxins  are  most  actively 
going  on.  The  desperate  state  of  the  patient  is  the  result  chiefly  of 
the  struggle  in  these  outlying  portions  and  he  stands  or  falls  accord- 
ing to  the  outcome  of  this  conflict. 

As  the  disease  which  threatens  the  patient's  life  is  now  perit- 
onitis so  must  the  treatment  be  directed  at  that  condition  and  any 
measure  aimed  at  the  appendix  itself  can  find  its  justification  only 
in  the  proof  that  the  associated  peritonitis  with  the  systemic  in- 
toxication will  be  helped  thereby.  Any  other  course  of  reasoning 
is  as  illogical  as  to  waste  time  trying  to  extinguish  the  match  which 
set  the  house  on  fire.  Will  removal  of  the  appendix  relieve  extensive 
diffuse  peritonitis?  The  mortality  records  of  any  clinic  which  have 
to  deal  with  this  type  of  cases  show  conclusively  that  it  will  not.     A 


Treatment  269 

considerable  number  will  still  die  of  peritonitis.  It  could  hardly 
be  expected  that  a  condition  which  no  longer  depends  upon  the 
presence  of  the  appendix  could  be  greatly  benefited  by  its  removal. 

Can  we  at  the  time  of  removal  of  the  appendix  institute  such 
other  measures  as  more  favorably  to  influence  the  associated  diffus- 
ing peritoneal  inflammation?  From  an  experience  covering  the 
entire  modern  period  of  the  development  of  the  subject,  and 
after  a  thorough  trial  of  the  surgical  measures  proposed  for  this 
purpose,  including  evisceration,  irrigation  with  antiseptic  or  bland 
solutions,  rough  and  gentle  sponging,  extensive  and  limited  drainage 
with  gauze  and  tubular  drains,  all  of  these  procedures  representing 
different  epochs  of  advance,  I  am  convinced  that  the  less  interference 
with  diffuse  peritonitis  when  at  the  height  of  its  systemic  effects,  the 
better  for  the  patient.  By  interference  is  meant  not  merely  opera- 
tive interference  but  medical  interference  as  well.  Many  of  these 
patients  owe  their  desperate  condition  to  the  well  meant  but  mis- 
directed efforts  of  their  physicians.  More  dangerous  than  the  sur- 
geon's scalpel  is  the  harmless  looking  cathartic  pill  or  purgative 
draught  which  is  almost  universally  given  in  the  early  stages  of 
this  disease.  The  prevalence  of  this  practice  constitutes  one  of  the 
greatest  therapeutic  follies  of  the  day  and  it  is  not  too  much  to  say 
that  the  majority  of  cases  of  peritonitis  resulting  from  appen- 
dicitis are  instances  of  ''therapeutic  peritonitis"  due  to  medical 
maltreatment. 

An  acutely  inflamed  appendix  does  not  differ  from  any  other 
inflamed  member  in  its  need  for  rest  and  protection.  The  stiffened 
overlying  muscles,  the  shallow  breathing,  the  protest  against  pressure 
and  disinclination  for  food  all  proclaim  this  fact.  Every  effort  of 
nature  is  set  at  naught  by  the  violent  peristalsis  excited  by  purgation. 
The  inflammation  of  the  appendix  itself  is  increased  and  when  once 
it  has  been  transmitted  to  the  surrounding  viscera  the  inflammatory 
products  are  distributed  throughout  the  cavity  by  the  writhing  action 
of  the  intestines  which  at  the  same  time  prevents  limitation  of  the 
process  by  cohesion  of  the  coils.  Surgeons  are  now  awake  to  this 
danger  and  are  urging  the  abandonment  of  purgatives  and  laxatives 
in  the  treatment  not  only  of  peritonitis  but  of  any  intestinal  disease 
which  is  likely  to  give  rise  to  it,  chief  of  which  is  appendicitis.  In 
my  experience  purgation  and  perforation  are  practically  synonymous. 


270  Appendicitis 

Both  food  and  drink  must  be  prohibited  for  the  same  reason. 
This  fact  is  better  known  than  the  above  and  is  more  generally 
practised.  There  should  be  no  relaxation  from  this  rule.  Even  ice 
should  not  be  given  since  a  small  amount  of  fluid  in  the  stomach 
will  excite  peristalsis  extending  along  the  entire  alimentary  tube. 
The  fact  that  fluids  must  reach  the  lower  small  and  large  intestine 
before  they  are  absorbed  makes  clear  the  reason  for  this  stringent 
rule.  Not  only  does  the  peristaltic  action  of  the  intestines  thus  do 
harm  after  the  ingestion  of  food  or  fluid  but  the  organism  rebels 
against  the  material  introduced  into  the  alimentary  tract  and 
vomiting  is  caused.  The  effect  of  constant  vomiting,  or  even  nausea 
in  disturbing  the  rest  of  the  peritoneum  is  only  too  evident.  Not 
only  may  vomiting  directly  cause  a  spread  of  infectious  material  by 
stirring  up  the  abdominal  viscera  but  by  its  disturbing  action  upon 
the  omentum  it  prevents  this  important  structure  from  effectually 
surrounding  the  infected  area. 

Since  it  is  so  important  to  prevent  peristalsis  and  vomiting,  the 
necessity  of  lavage  can  at  once  be  appreciated.  We  must  not 
only  see  to  it  that  no  food  enters  the  stomach,  but  it  is  of  equal 
importance  to  relieve  the  stomach  of  whatever  it  contains.  This 
should  be  done  whether  the  patient  has  vomited  profusely  or  is 
merely  nauseated  or  regurgitating.  After  the  patient  has  vomited 
freely  if  the  stomach  tube  is  passed  it  will  be  seen  that  the  stomach 
has  not  been  emptied.  In  other  cases  a  large  amount  of  foul  fluid 
may  accumulate  in  the  stomach  without  causing  more  than  slight 
nausea  or  regurgitation  and  at  times  there  may  be  no  symptoms  at 
all  of  its  presence.  Hence  the  importance  of  using  the  stomach 
tube  freely.  Above  all  there  should  be  no  temporizing  with  gastric 
sedatives  which  have  absolutely  no  place  in  the  treatment  of  this 
condition.  The  mouth  may  be  kept  clean  and  moist  by  suitable 
washes  or  by  damp  gauze. 

The  sitting  posture  is  essential  in  aiding  the  gravitation  of 
infective  fluid  exudates  from  the  diaphragmatic  area  where  absorp- 
tion is  most  active  into  the  pelvis  where  absorption  is  least  active 
and  surgical  treatment  easiest  and  most  promising  should  it  become 
necessary  to  evacuate  a  purulent  collection.  One  or  two  ice-bags 
upon  the  abdomen  give  comfort  and  aid  in  keeping  the  patient  quiet 
and  lastly  but  not  least  discourage  meddling  examinations  which 


Treatment  271 

tend  to  spread  infection.  The  ice-bag  should  not  be  allowed  to 
remain  for  any  length  of  time  in  direct  contact  with  the  skin  as 
serious  necrosis  may  be  caused.  A  towel  folded  about  the  bag  will 
prevent  this  complication.  The  patient  should  not  be  permitted  to 
believe  that  the  comfort  induced  by  the  ice-bag  is  indicative  of  im- 
provement in  the  disease  any  more  than  would  be  the  case  by 
morphia  or  a  drug  anodyne.  An  unfortunate  notion  has  become 
current  among  the  laity  that  appendicitis  can  be  "frozen  out." 
The  profession  alone  is  responsible  for  this  idea  and  indirectly  for 
the  toll  of  deaths  which  are  due  to  this  mistaken  practice. 

The  imperative  need  of  water  is  satisfied  by  rectal  instillation  of 
normal  salt  solution  which  is  best  given  by  the  continuous  method 
of  Murphy.  • 

While  it  is  true  that  the  Murphy  method  is  primarily  intended 
for  post-operative  use  and  finds  its  greatest  field  of  usefulness  there, 
nevertheless,  it  is  true  that  it  is  equally  beneficial  before  operation. 

In  a  patient  who  suffers  from  peritonitis  the  tissues  are  dehy- 
drated. The  splanchnic  vessels  are  dilated,  withdrawing  a  large 
amount  of  blood  from  the  general  circulation  and  fluids  ac- 
cumulate within  the  lumen  of  the  intestine  and  in  the  abdominal 
cavity.  The  kidneys,  since  the  blood  does  not  reach  them  in  normal 
volume  and  under  normal  pressure,  fail  to  eliminate  the  poisonous 
products  of  infection.  The  heart  is  unable  to  functionate  properly 
because  of  the  lessened  available  volume  of  blood,  and  whatever 
toxins  are  absorbed  by  the  tissues  remain  in  more  concentrated  form 
because  of  the  diminution  in  the  bodily  fluids  as  a  whole. 

By  the  use  of  continuous  enteroclysis  we  are  able  to  supply  the 
much  needed  water  to  the  body  in  quantities  far  in  excess  of  that 
which  can  be  satisfactorily  introduced  by  any  other  method.  In 
addition  to  its  beneficial  action  in  furnishing  the  depleted  tissues 
and  particularly  the  circulatory  system  with  a  sufficient  quantity  of 
fluid  it  exerts  a  directly  beneficial  effect  upon  the  peritoneum  itself. 
In  post-operative  cases  drained  by  rubber  dam,  tube  or  gauze,  where 
the  Murphy  method  is  used  the  drainage  may  be  so  profuse  as  to 
suggest  direct  transudation  from  the  supersaturated  tissues  thus 
mechanically  aiding  in  the  removal  of  infective  products  and  in  a 
sense  transforming  the  peritoneum  from  an  absorbing  to  a  secret- 
ing serous  membrane. 


272  Appendicitis 

The  method  of  giving  continuous  saline  enteroclysis  is  com- 
paratively simple,  but  the  fundamental  principle  must  be  correctly 
applied.  The  essential  point  is  to  introduce  the  fluid  into  the 
bowel  under  a  pressure  which  is  just  sufficient  to  overcome  the 
intra-abdominal  pressure. 

The  fluid,  kept  at  an  even  temperature  of  110°  F.,  is  contained 
in  a  reservoir  the  base  of  which  is  but  four  to  eight  inches  higher 
than  the  level  of  the  rectal  tube  itself.  The  rectal  tube,  preferably 
the  Murphy  hard  rubber  tube,  is  connected  with  the  container  by  a 
flexible  rubber  tube.  The  curved  rectal  tube  is  used  for  the  sitting 
posture  and  the  straight  tube  for  the  recumbent  position.  A  tube 
with  numerous  small  lateral  openings  is  preferable  to  one  with  a 
single  large  opening  since  there  is  less  danger  of  occlusion  by  fascal 
material.  In  children  an  ordinary  self-retaining  female  urethral 
catheter  introduced  just  beyond  the  internal  sphincter  will  be  found 
to  work  well  and  is  somewhat  less  annoying  to  the  small  patient. 
The  tube  is  introduced  well  into  the  rectum  and  the  fluid  allowed 
to  run  by  gravity.  There  is  not  enough  pressure  forcibly  to  distend 
the  bowel,  but  just  enough  to  keep  it  well  filled  and  continuously 
to  renew  that  which  is  absorbed.  Flatus  easily  passes  out  through 
the  large  tube. 

Various  methods,  electrical  and  otherwise,  have  been  devised 
for  keeping  the  saline  at  an  even  temperature,  but  in  the  absence 
of  these,  the  same  result  can  be  accomplished  by  constant  watching 
of  the  solution  itself  and  by  the  use  of  hot-water  bags  placed  about 
the  tube  near  the  rectal  end. 

At  no  time  should  the  saline  flow  rapidly.  When  this  occurs 
the  level  of  the  top  of  the  fluid  must  be  lowered  so  as  to  reduce  the 
pressure. 

The  amount  of  saline  that  can  be  absorbed  when  this  method 
of  administration  is  used  is  truly  surprising.  Adult  patients  very 
frequently  will  take  as  much  as  500  c.c.  (16  oz.)  in  three  hours. 
The  average  patient  will  have  no  difficulty  in  taking  100  c.c.  (3  oz.) 
per  hour.  Children  average  about  1800  c.c.  (60  oz.)  in  twenty- 
four  hours.  In  order,  however,  to  accomplish  the  best  results 
several  points  must  be  closely  watched. 

Distention  which  progressively  increases  is  an  indication  that 
too  much  fluid  is  being  injected,  and  calls  for  either  a  marked 


Treatment  273 

lowering  of  the  pressure  of  the  fluid  or  a  total  cessation  of  the' 
treatment  for  a  longer  or  shorter  interval.  Per  contra,  failure  to 
absorb  the  fluid  calls  for  a  slight  increase  in  the  elevation  of  the 
fluid  in  the  container. 

Puffiness  of  the  eyes  with  oedema  of  the  legs  and  the  passage  ' 
of  excessive  amounts  of  urine  probably  indicate  that  the  patient 
is  receiving  and  absorbing  an  excess  of  fluid  and  I  regard  these 
symptoms  as  an  indication  to  lessen  the  administration  of  the 
saline.  Occasionally  the  pressure  of  painful  haemorrhoids  will 
not  permit  the  retention  of  the  rectal  tube  for  a  long  period  of  time. 
In  such  cases  the  fluid  may  be  given  at  regular  intervals  in  quantities 
of  250  c.c.  (8  oz.).  Fortunately  contraindications  and  unfavorable 
symptoms  in  the  use  of  the  continuous  method  are  exceedingly 
rare.  Failure  to  retain  or  absorb  the  fluid  is  almost  without  excep- 
tion an  evidence  of  improper  methods  of  administration. 

Alimentation  is  rarely  a  factor  to  be  considered  in  the  period 
during  which  the  patient  is  deprived  of  food  by  mouth.  It  may  at 
times  seem  advisable  to  add  small  quantities  of  expressed  predi- 
gested  beef  juice  to  the  saline  infusion.  Glucose  may  be  used  also 
in  quantity  to  make  2  to  5  per  cent,  solution  since  this  may  be  both 
absorbed  and  utilized  as  such  by  the  body.  The  many  complex 
formulas  for  nutrient  enemas  are  worthless  and  as  usually  employed, 
rectal  alimentation  is  merely  a  euphemism  for  absolute  starvation. 

Anodynes  are  rarely  necessary  and  should  be  given  only  on  the 
strongest  indications,  and  then  only  in  the  smallest  quantity.  For 
pain  and  restlessness  1-20  gr.  of  morphia  will  usually  prove  suffi- 
cient. A  sympathetic  well-trained  nurse  is  more  efficient  than 
opiates  which  cause  distention  and,  there  is  reason  to  believe  on 
experimental  grounds,  interfere  with  the  activities  of  the  leucocytes 
which  are  so  important  in  defence. 

If  treated  in  this  manner  almost  without  exception,  unless 
the  patient  be  already  moribund,  the  diffusing  process  will  not 
only  be  checked  but  the  peritoneal  inflammation  in  the  outlying 
areas  will  subside  and  localize  about  the  region  of  the  appendix. 
Coincidently  there  is  marked  improvement  in  the  facial  expression, 
general  appearance  and  feeling  of  the  patient. 

As  the  process  localizes,   at  what  time  should  we  intervene? 
Should  we  wait  until  a  sharply  defined  abscess  has  formed  and 
18 


2  74  Appendicitis 

become  firmly  walled  off  ?  This  method  has  strong  advocates. 
It  has  nevertheless  not  been  my  practice  and  results  justify  me  in 
speaking  against  it. 

It  is  not  possible  to  give  any  set  time  in  days  or  hours  when 
operation  should  be  attempted  since  individual  cases  vary  so  greatly 
in  their  response  to  treatment.  Success  in  inducing  localization  is 
attended  by  a  marked  decrease  in  tenderness  and  rigidity  in  the  upper 
abdomen.  Simultaneously,  distention  subsides  in  these  areas. 
The  patient  becomes  more  comfortable.  The  pulse  and  tempera- 
ture assume  a  more  equable  and  lower  level.  Peristalsis  is  restored 
and  there  is  a  beginning  of  the  free  passage  of  gas  and  frequently 
faecal  material.  At  the  same  time  the  local  signs  become  more 
marked,  and  it  is  evident  that  the  area  of  severe  inflammation  may  be 
attacked  directly  without  loss  of  time  or  the  necessity  for  exploration. 
When  this  condition  of  affairs  is  present  it  is  time  to  operate.  Go 
quickly  and  directly  to  the  focus.  Deal  with  that  and  that  alone. 
"The  more  thorough  the  operation,  the  more  quickly  the  patient 
dies."  Reach  it  by  the  so-called  extra-peritoneal  route  if  possible, 
making  the  incision  far  out  toward  the  pelvic  brim  and  working  up 
under  the  inflammatory  mass.  If  it  is  necessary  to  go  into  the  gen- 
eral cavity,  protect  it  well  with  moist  gauze  pads  before  treating  the 
site  of  inflammation.  Usually  an  abscess  will  be  found.  Mop 
away  the  pus  and  search  for  the  appendix.  It  should  be  removed 
unless  the  search  entails  too  great  loss  of  time  or  the  extensive  break- 
ing up  of  surrounding  fresh  adhesions.  As  a  rule  a  tube  should  be 
passed  into  the  pelvis  to  make  sure  that  it  contains  no  purulent 
collection.  The  proper  disposal  of  drainage  in  accordance  with  the 
conditions  and  the  closure  of  the  wound  except  in  so  far  as  it  is  neces- 
sary to  leave  space  for  drainage  to  emerge,  complete  the  operation. 
Results  with  this  method  have  been  so  good  as  to  make  it  preferable 
in  my  mind  to  waiting  several  days  after  localization  for  the  produc- 
tion of  firmer  adhesions  about  the  abscess.  I  have  known  abscesses 
to  rupture  into  the  general  cavity  while  under  observation  and  when 
this  occurs  it  generally  causes  a  virulent  and  fatal  peritonitis.  It  is 
more  difficult  to  secure  the  appendix  when  a  large  abscess  has  been 
allowed  to  form  and  experience  has  now  shown  that  the  appendix  is 
but  rarely  completely  destroyed  by  abscess  formation  and  in  a  con- 
siderable percentage  of  cases  gives  subsequent  trouble.     Neither  do 


Treatment  275 

I  look  with  favor  upon  permitting  dense  adhesions  to  form  within 
the  abdomen  if  it  can  be  prevented.  Convalescence  is  apt  to  be  more 
protracted  the  larger  the  abscess,  and  the  abdominal  wall  can  never 
be  so  well  approximated  to  avoid  later  hernia. 

Treatment  Between  Attacks. 

If  a  patient  under  purely  medical  treatment  is  so  lucky  as  to  re- 
cover from  his  first  acute  attack  of  appendicitis,  it  is  in  my  opinion 
the  duty  of  his  attending  physician  to  advise  the  removal  of  the 
offending  organ  as  soon  as  his  convalescence  has  passed.  The 
appendicular  inflammation  has  become  chronic,  and  in  nearly  all 
cases  the  patient  will  be  subject  to  recurring  attacks,  and  not  in- 
frequently will  be  more  or  less  of  an  invalid  during  the  intervals. 
It  must  also  be  borne  in  mind  that  there  are  certain  results  of 
the  inflammation  that  are  not  manifest  to  the  patient,  such  as 
bands  of  peritoneal  adhesions;  that  these  may  cause  obstruction  or 
chronic  inflammation  of  the  intestine,  etc.;  and  that  they  may 
inaugurate  their  deleterious  consequences  at  any  moment. 

Hence  under  no  circumstances  should  any  one  who  has  once  had 
an  attack  of  appendicitis,  and  whose  appendix  has  not  been  removed, 
ever  consider  himself  safe  from  recurrence;  and  he  should  never 
deprive  himself  of  the  facilities  for  operative  treatment,  which  may  at 
any  moment  be  imperatively  demanded.  To  indulge  the  hope  that 
the  lumen  of  the  appendix  has  become  obliterated  is,  to  say  the  least, 
worse  than  foolish. 

To  prevent  recurrence  of  an  attack,  the  patient  positively  re- 
fusing operation,  he  must  live  by  rule,  considering  himself  a  semi- 
invalid.  He  should  be  cautioned  to  lead  a  regular,  hygienic  and 
abstemious   life,    and   to    avoid   dietetic    and   other   indiscretions. 

Attention  must  be  directed  to  the  clothing,  which  should  be 
changed  to  suit  the  varying  conditions  of  the  weather,  and  which 
should  afford  sufficient  protection  without  exciting  the  skin  to  undue 
activity.  The  feet  especially  must  be  protected  against  the  inclem- 
encies of  the  weather.  Only  the  simplest  and  most  easily  digested 
food  should  be  eaten,  and  of  a  kind  that  will  leave  least  residue  in  the 
intestinal  tract.  All  coarse  food,  such  as  grits,  coarse  oat-meal, 
tough  meats,  etc.,  must  be  scrupulously  avoided.     Not  only  must 


276  Appendicitis 

the  food  be  selected  with  care,  but  it  must  be  taken  at  regular 
intervals,  and  should  always  be  eaten  slowly,  and  be  thoroughly 
masticated.  There  can  be  little  doubt  that  the  lunches  of  many 
business  people — which  usually  consist  of  indigestible  food,  bolted 
without  mastication,  and  at  irregular  hours — are  a  fruitful  source  of 
recurring  attacks  of  appendicitis.  The  condition  of  the  teeth  must 
be  ascertained  and,  if  necessary,  a  set  of  false  teeth  should  be 
procured.  Regular  action  of  the  bowels  must  be  insisted  upon. 
This  may  best  be  accomplished  by  the  cultivation  of  regular  habits 
in  this  particular,  whether  there  be  an  inclination  to  stool  or  not; 
by  a  diet  carefully  selected  for  this  purpose,  including  various  laxa- 
tive fruits,  raw  or  stewed,  such  as  prunes,  apples,  and  dates,  or 
oranges,  figs,  etc.  There  seems  no  reason  to  believe  that  the  seeds  of 
figs  and  other  fruits  lead  to  appendicitis.  All  purges  should  be 
avoided  if  possible,  and  attention  should  rather  be  directed  to  the 
treatment  of  the  intestinal  indigestion,  which  is  usually  the  basis  of 
the  intractable  constipation  which  is  seen  in  some  of  these  cases. 
If  the  constipation  itself  does  not  become  the  exciting  cause  of  another 
attack  of  appendicitis,  the  use  of  cathartics  and  purges  to  overcome 
this  constipation  will  be  extremely  apt  to  pi-oduce  a  recurrence; 
hence  enemata  are  to  be  preferred  whenever  practicable.  It  must  be 
borne  in  mind,  however,  that  the  intestinal  indigestion  which  is 
present  in  these  cases,  and  which  is  blamed  for  the  chronic  constipa- 
tion, is  not  infrequently  engendered  or  maintained  by  the  associated 
appendicitis,  and  that  relief  cannot  be  expected  under  such  circum- 
stances  until   the   offending   appendix   is   excised. 

It  is  barely  possible  that  if  any  patient  could  be  found  who 
would  be  induced  to  lead  a  life  of  such  exemplary  regularity  as  is 
enjoined  upon  him,  he  might  be  free  from  further  attacks  of  appen- 
dicitis for  the  rest  of  his  life;  but  as  such  patients  are  the  rare  ex- 
ception, it  is  not  wonderful  that  from  75  to  80  per  cent,  of  patients 
become  subject  to  recurring  attacks  of  greater  or  less  severity. 
It  is  also  the  exception  for  the  subsequent  attacks  to  be  milder  than 
those  which  preceded;  and  when  we  consider  the  added  difficulties 
in  operation  caused  by  the  old  adhesions,  it  is  simply  one  more 
argument  in  favor  of  the  removal  of  the  appendix  at  the  commence- 
ment of  the  first  attack. 


Treatment  277 


TECHNIC  OF  OPERATION. 

Under  this  heading  it  is  convenient  to  consider:  (i)  The  prepara- 
tion of  the  patient;  (2)  the  details  of  the  operation  itself;  and  (3)  the 
after-treatment.  The  treatment  of  the  various  complications  and 
sequels  of  appendicitis  is  discussed  in  the  final  chapter. 

Preparation  of  the  Patient. — ^In  acute  cases  of  any  severity 
the  patient  is  usually  in  bed  when  first  seen;  but  as  already  recom- 
mended, in  no  case  should  he  be  allowed  to  stay  out  of  bed.  In 
chronic  cases  the  patient  should  be  confined  to  bed  for  one  or  two 
days  preceding  the  time  set  for  operation,  and  his  diet  should  be 
light  and  easily  digested.  Acute  cases  as  already  recommended 
receive  nothing  by  mouth.  It  is  impossible  to  sterilize  the  large 
intestine  or  the  lower  portion  of  the  small  intestines.  It  is  worse 
than  useless  to  employ  drugs  with  this  object.  Restriction  of  bac- 
terial activity  and  multiplication  may,  however,  be  effected  by 
limiting  the  diet,  particularly  the  proteid  factor.  Cooked  foods  are 
best  as  they  are  thereby  sterilized  and  do  not  add  to  the  ordinary 
intestinal  flora.  If  the  patient  has  not  been  seen  some  time  before 
operation  is  performed  it  is  useless  to  attempt  any  extensive  steriliza- 
tion of  the  mouth  itself.  In  the  case  of  pyorrhea  this  may  be  harm- 
ful by  causing  added  irritation  and  increase  of  the  gingival  discharge. 
If  there  be  sufficient  time  it  is  advisable  to  have  the  teeth  and  gums 
brought  into  a  healthy  condition.  Ordinarily  it  suffices  to  have  the 
patient  wash  the  mouth  frequently  with  a  mild  alkaline  antiseptic 
solution  and  use  a  soft  bristle  or  felt  brush  upon  the  teeth. 

In  the  examination  of  the  patient  special  attention  should  be 
paid  to  the  heart,  lungs  and  kidneys.  In  the  presence  of  acute 
pulmonary  complications,  it  may  be  necessary  to  defer  operation. 
Chronic  lung  disease  requires  special  consideration  of  the  mode  of 
anaesthesia  to  be  employed.  The  heart,  as  has  already  been  stated, 
should  be  regarded  from  the  standpoint  of  its  functional  efficiency 
rather  than  with  reference  to  the  specific  lesions.  Should  muscular 
weakness  be  suspected  appropriate  cardiac  stimulants  should  be 
given  prior  to  operation  if  time  permits.  Perhaps  the  most  impor- 
tant of  the  preliminary  examinations  is  the  determination  of  renal 
sufficiency.     Especially    is    this    true    of    older    individuals.     The 


278  Appendicitis 

specific  gravity  and  the  daily  quantity  are  at  once  the  simplest  and 
best  indexes  of  functional  capacity.  It  is  advisable  also  to  make  the 
ordinary  chemical  and  microscopical  examinations  for  the  presence 
of  abnormal  constituents.  If  renal  elimination  is  deficient  steps 
should  be  taken  to  increase  secretion,  bearing  in  mind  always  that 
water  is  the  best  diuretic.  In  chronic  cases  water  may  be  given 
freely  by  mouth,  but  in  acute  appendicitis  it  should  be  administered 
by  rectum.  Occasionally  it  may  be  beneficial  to  give  it  in  the  form 
of  salt  solution  beneath  the  skin  or  into  a  vein,  but  this  is  rarely 
necessary  or  advantageous  in  preliminary  treatment.  It  is  best  to 
question  each  patient  as  to  the  existence  of  an  acute  bronchial  or 
nasal  cold  and  if  present  to  defer  operation  except  in  acute  cases. 
In  chronic  cases  the  bowels  should  be  evacuated  by  a  laxative,  pref- 
erably castor  oil,  the  day  before  the  operation  and  in  every  case  an 
enema  should  precede  the  operation  unless  haste  is  necessary  be- 
cause of  the  acuteness  of  the  disease.  The  thoroughness  with  which 
these  preoperative  conditions  and  others  special  to  the  cases  may  be 
followed  out  will  depend  in  a  degree  upon  the  urgency  of  the  con- 
dition. As  a  rule  protracted  pre-operative  treatment  is  unwise  as 
it  has  a  bad  effect  upon  the  morale  of  the  patient.  In  the  ultra- 
acute  cases  the  preparation  of  the  patient  practically  resolves  itself 
into  preparation  for  the  operation  itself. 

Where  time  and  the  constitutional  condition  of  the  patient 
permit,  all  demands  of  what  may  be  called  ordinary  cleanliness 
should  be  met.  That  is  to  say  the  patient  should  receive  a  hot  tub 
bath  on  the  evening  of  the  day  before  operation.  An  entire  change 
of  the  personal  clothing  of  the  patient  and  of  the  bed  linen  should  be 
made  on  the  morning  of  operation.  The  entire  abdomen  and  espe- 
cially the  pubic  region  should  be  scrubbed  with  tincture  of  green 
soap  and  all  hair  removed  from  these  localities  by  shaving,  after 
which  a  further  and  thorough  scrubbing  (using  a  piece  of  gauze  or 
a  soft  brush)  with  soap  and  water  should  be  made.  After  rinsing 
off  the  epithelial  debris  with  sterile  water  the  fatty  and  sebaceous 
materials  are  removed  with  alcohol.  Harrington's  solution  is  then 
briefly  applied  with  a  sponge  and  the  skin  again  thoroughly  flushed 
with  a  i-iooo  solution  of  bichloride  of  mercury.  Dry  sterile  gauze 
should  then  be  placed  over  the  abdomen  and  secured  in  such  a  man- 
ner that  it  will  not  become  displaced.     It  is  assumed  that  the  nurse 


Treatment  279 

or  other  attendant  who  is  entrusted  with  the  preparation  has  not 
previously  handled  septic  or  infected  materials  and  that  the  hands 
should  be  thoroughly  cleansed  and  rubber  gloves  donned  with  the 
same  scrupulous  care  that  the  surgeon  himself  must  exercise. 

When  peritonitis  or  abscess  is  present  the  scrubbing  should  be 
exceedingly  gentle  to  avoid  rupture  and  the  dissemination  of  infect- 
ive products.  When  time  is  important  this  preparation  may  be 
carried  out  on  the  table  after  the  administration  of  the  anaesthetic 
has  begun.  If  an  interval  of  several  hours  has  elapsed  between  the 
preparation  and  operation  it  is  advisable  to  scrub  the  skin  thoroughly 
with  alcohol  or  Harrington's  solution  before  starting  the  operation. 

The  above  is  the  method  of  preparation  which  has  given  me 
great  satisfaction.  It  is  but  fair  to  say  that  there  are  many  variations 
of  this  procedure  which  give  equally  good  results.  The  principle 
is  cleanliness,  it  matters  not  how  that  is  attained.  The  method  of 
disinfection  of  the  skin  by  alcoholic  solutions  of  iodine  has  proved 
to  be  satisfactor\'  if  the  necessary  precautions  are  observed.  The 
solution  should  be  perfectly  fresh  and  preferably  not  stronger  than 
5  per  cent.  The  skin  must  be  dry  before  it  is  applied;  it  should 
not  be  used  in  too  great  concentration  as  dermatitis  and  often 
blistering  may  result.  Some  individuals  have  an  idiosyncrasy 
which  makes  them  very  susceptible  to  irritation  of  the  skin  by 
iodine. 

In  abdominal  operations  care  should  be  taken  not  to  permit  the 
intestines  coming  in  contact  with  the  iodine-covered  skin  because  of 
the  danger  of  causing  necrosis  of  the  endothelium  of  the  peritoneum. 

The  anaesthetic  of  choice  in  all  abdominal  work  is  ether  given 
by  the  open  drop  method.  It  may  with  advantage  be  preceded  by 
nitrous  oxide.  If  nitrous  oxide  is  employed  in  this  way  I  have 
found  that  subsequent  etherization  is  sometimes  not  so  satisfactory 
as  in  cases  where  ether  is  given  from  the  outset.  In  ordinary  cases 
therefore  simple  etherization  is  preferable.  In  children  and  highly 
nervous  patients  the  preliminary  use  of  nitrous  oxide  is  of  distinct 
value  in  that  it  acts  more  quickly  and  lessens  the  psychic  effect  which 
may  be  equally  as  harmful  as  the  operation  itself.  As  time  goes 
on  I  find  fewer  and  fewer  cases  in  which  complications  demand  the 
substitution  of  one  of  the  other  modes  of  anaesthesia.  Pneumonia, 
acute  bronchitis  and  in  general  the  acute  pulmonary  conditions 


28o  Appendicitis 

contraindicate  etherization.  In  chronic  bronchitis  with  copious 
secretion  ether  is  more  likely  to  be  followed  by  pneumonia  than  is 
one  of  the  other  methods.  In  desperate  cases  upon  whom  the 
surgeon  proposes  to  carry  out  some  simple  procedure,  the  exact 
limits  of  which  he  knows  beforehand,  such,  for  instance,  as  the 
incision  of  an  abscess,  I  favor  local  anaesthesia  or  the  use  of  nitrous 
oxide  and  oxygen.  Spinal  anaesthesia  from  personal  experience 
and  the  literature  I  consider  too  dangerous  for  routine  employment. 
Where  a  general  anaesthetic  is  contraindicated  and  the  operative 
difficulties  are  likely  to  be  great  it  may  be  used.  On  account  of  its 
immediate  dangers  and  remote  toxic  effects,  the  field  of  chloroform 
is  becoming  more  and  more  restricted  and  it  is  probable  that  we  can 
now  dispense  with  it  altogether  as  an  anaesthetic  for  this  type  of 
work.  If  used,  it  should  always  be  preceded  by  atropine  to  counter- 
act its  early  inhibitory  cardiac  action  to  which  sudden  death  may  be 
due.  Nitrous  oxide  and  oxygen  given  simultaneously  is  the  only 
active  competitor  of  ether  at  present.  The  anaesthesia  which  is 
thus  induced  is  less  satisfactory  for  abdominal  work  than  is  ether 
anaesthesia  and  since  the  safety  of  the  patient  is  so  dependent  upon 
a  favorable  condition  for  surgical  work,  or  in  other  words  upon  the 
ease  and  rapidity  with  which  the  surgeon  can  carry  out  the  required 
procedure,  in  my  opinion  ether  is  still  preferable. 

The  most  important  thing  in  anaesthesia  is  to  have  a  competent 
anaesthetist.  In  this  country  we  have  been  tardy  in  recognizing 
and  acting  upon  this  fact.  It  is  better  to  trust  the  more  dangerous 
anaesthetic  to  an  experienced  anaesthetist  than  to  have  the  safest 
administered  by  a  tyro  as  is  too  frequently  done.  The  anaesthetist 
has  the  life  of  the  patient  in  his  keeping  no  less  than  the  surgeon. 
Unskillful  administration  may  be  responsible  for  death  either 
directly  or  by  hampering  the  surgeon  in  the  successful  performance 
of  his  manipulations.  No  one  can  be  a  good  anaesthetist  unless  he 
or  she  has  had  considerable  experience  and  is  constantly  doing  this 
sort  of  work.  The  development  of  specialists  in  anaesthesia  is 
therefore  inevitable  in  all  surgical  centers  and  should  be  encouraged. 
In  my  clinic  the  anaesthesia  is  given  by  nurses  specially  trained 
for  this  work.  The  entrance  of  women  into  this  field  has  seemed 
to  me  to  be  a  step  in  advance,  as  it  is  comparatively  easy  to  find  a 
woman  who  will  devote  her  whole  time  and  attention  to  this  one 


Treatment 


2»I 


branch.  So  far  as  adaptability  is  concerned,  while  it  is  true  that 
not  everyone  is  fitted  to  become  a  good  anaesthetist  I  have  found  the 
women  who  are  attracted  to  this  work  to  be  equally  as  satisfactory 
as  men.     It  is  unsafe  to  entrust  anajsthesia  to  untrained  interhes. 

The  Operation. — ^There  are  in  use  several  incisions  through 
the  abdominal  wall,  each  of  which  has  its  advantages  in  certain 
cases.  In  any  case,  the  incision  should  be  in  the  right  iliac  region, 
and  should  aim  to  secure  the  readiest  access  to  the  appendix,  the 
greatest  facilities  for  drainage  (when  this  is  required),  and  the  least 


Fig.  14. — Skin  Incisions  for  Appendicitis. 
I.  The  Simple  incision  through  right  rectus  muscle.     2.  Incision  of  Battle,  Kammerer, 
and    Jalaguier.     3.   McBurney's   incision.     4.    Hancock's   incision.     5.    Oblique 
lumbar  incision. 


probability  of  subsequent  hernia.  The  median  incision  for  appen- 
dicitis cannot  be  too  strongly  condemned:  it  is  not  founded  on 
good  anatomical  grounds,  and  is  therefore  irrational  and  dangerous, 
particularly  if  pus  complicates  the  case. 

Abdominal  incisions  may  be  classed  as  simple  or  direct  and 
indirect.  In  the  former  variety  all  the  layers  of  the  abdominal 
wall  are  divided  in  the  same  plane,  and  in  the  latter  these  layers 
are  divided  in  different  planes,  the  lines  of  the  incision  crossing, 


282  Appendicitis 

as  in  the  McBurney  incision,  or  being  parallel  but  not  coincident, 
as  in  the  incision  practised  by  Battle,  Kammerer,  and  Jalaguier. 

That  incision  which  I  usually  employ,  and  prefer  for  all  but 
the  exceptional  cases,  is  the  simple  incision  passing  through  the 
outer  half  of  the  right  rectus  muscle.  This  incision  is  easy  and 
rapid  of  execution,  can  be  enlarged  at  will  or  made  of  insignificant 
size,  affords  ample  drainage  facilities,  and  is,  I  think,  not  more 
likely  to  result  in  hernia  formation  than  any  other  incision.  Often 
a  small  incision  will  be  sufficient,  yet  those  who  have  not  had  con- 
siderable experience  in  surgery  should  rather  make  the  incision 
too  large  than  too  small.  When  adhesions  or  other  complicating 
features  are  present  the  incision,  if  it  be  not  already  sufficiently 
large,  should  at  once  be  made  so  lest  injury  be  done  the  tissues  in 
an  attempt  to  operate  through  an  opening  which  does  not  give 
full  access  to  the  area  to  be  dealt  with. 

I  frequently  remove  the  appendix  in  clean  cases  through  an 
incision  in  the  peritoneum  only  long  enough  to  admit  the  index- 
finger.  The  line  of  the  deep  epigastric  vessels  should  be  borne  in 
mind,  and  the  incision  placed  above  it.  They  run  in  an  approxi- 
mately straight  course  from  their  origin  from  the  external  iliac 
vessels  just  above  Poupart's  ligament  to  the  umbilicus.  Hence  the 
lower  end  of  an  incision  of  about  two  inches  in  length  need  not 
divide  them.  After  dividing  the  skin  and  superficial  fascia,  the 
anterior  sheath  of  the  rectus  is  exposed.  This  consists  of  two 
layers,  the  aponeurosis  of  the  external  oblique  muscle  and  the 
anterior  layer  of  the  aponeurosis  of  the  internal  oblique.  By  divid- 
ing these  the  fibres  of  the  rectus  muscle  are  exposed.  These  are 
then  separated  longitudinally  with  the  handle  of  the  scalpel  and  the 
posterior  sheath  of  the  rectus,  the  transversalis  fascia  and  the 
preperitoneal  fat  are  exposed.  If  the  deep  epigastric  vessels  come 
into  view  they  may  be  pushed  aside  or  if  this  is  not  possible  they 
should  be  seized  with  two  pairs  of  forceps,  cut  between  and  tied 
before  proceeding  with  the  operation.  Nerves,  so  far  as  possible, 
should  be  displaced  either  upward  or  downward.  Below  the 
semilunar  fold  of  Douglas  the  posterior  sheath  of  the  rectus  is 
deficient — ^usually  below  a  line  from  one-third  to  one-half  the 
distance  from  the  umbilicus  to  the  symphysis  pubis.  Each  layer  of 
the  abdominal  wall  should  be  divided  to  approximately  the  same 


Treatment  283 

extent.  When  the  structures  lying  beneath  the  rectus  muscle  are 
exposed,  they  should  be  caught  in  haemostatic  forceps  at  each  side 
of  the  wound,  and  the  surgeon  should  cautiously  cut  through  them 
into  the  peritoneal  cavity,  with  the  belly,  not  the  point,  of  the 
scalpel.  As  this  is  done  traction  should  be  made  upon  the  two 
pairs  of  forceps,  so  as  to  raise  the  tissue  away  from  the  under- 
lying intestine,  and  care  should  be  exercised  to  cut  only  during  the 
process  of  expiration,  since  during  inspiration  the  intestines  are 
forced  against  the  parietal  peritoneum.  When  the  peritoneal 
cavity  has  been  opened  the  scalpel  is  to  be  laid  aside  and  the  peri- 
toneal wound  enlarged  with  blunt-pointed  scissors,  the  index- 
finger  of  either  hand  being  used  as  a  guide.  In  chronic  cases  a 
pair  of  dissecting  forceps  may  now  be  introduced  in  the  direction 
of  the  caecum,  which  is  grasped  and  brought  out  of  the  wound.  It 
is  recognized  by  its  longitudinal  bands,  its  size,  by  the  absence  of 
epiploic  appendages  and  its  pearly  color.  When  the  symptoms  are 
moderately  acute  the  surgeon  should  first  take  the  precaution  of 
introducing  his  index-finger  and  palpating  the  site  of  the  appendix 
to  determine  the  existence  of  a  mass  or  adhesions.  Under  these 
conditions  the  wound  should  at  once  be  enlarged  and  no  attempt 
made  to  deliver  the  appendix  blindly.  In  the  presence  of  pus  or 
whenever  the  attack  is  very  severe  the  incision  should  be  made  long 
enough  primarily  to  give  a  view  of  the  region  of  the  appendix.  In 
conditions  so  severe  as  this,  however,  it  will  usually  be  preferable 
to  make  the  incision  external  to  the  rectus  to  afford  more  direct 
access.  It  has  been  objected  to  the  simple  rectus  incision  that 
it  divides  the  abdominal  nerves  and  hence  by  relaxing  the  rectus 
muscle  predisposes  to  the  formation  of  a  hernia.  When  the  fascias 
are  correctly  approximated,  however,  this  does  not  occur  as  hernia 
formation  is  determined  to  a  much  greater  extent  by  defects  in  the 
fascia  than  by  muscular  atrophy.  Moreover,  if  ordinary  care  is 
used  in  small  incisions  it  is  rarely  necessary  to  injure  the  nerves. 

Another  somewhat  similar  incision  is  that  proposed  nearly 
simultaneously  by  Battle,  by  Jalaguier  and  by  Kammerer.  The 
anterior  sheath  of  the  rectus  is  exposed  and  opened,  as  in  the 
previous  incision,  but  a  little  closer  to  the  semilunar  line.  Here 
its  two  layers  are  quite  distinct.  The  rectus  muscle  is  then  separated 
from  the  outer  portion  of  its  sheath  and  is  drawn  toward  the  median 


284  Appendicitis 

line,  its  fibres  not  being  separated  as  in  the  incision  first  described, 
the  surgeon  working  around  its  external  border.  Its  posterior 
sheath,  the  transversalis  fascia,  preperitoneal  fat,  and  peritoneum 
are  then  opened  well  toward  the  median  line  of  the  muscle — ^midway 
between  the  linea  semilunaris  and  the  linea  alba.  By  this  means 
the  incisions  through  the  different  layers  of  the  abdominal  wall 
are  not  superposed  one  directly  on  the  other.  This  incision  is  not 
adapted  for  pus  cases,  because  of  its  valve-like  formation,  but 
when  completely  sutured  offers  a  very  good  protection  against 
hernia  formation. 

The  McBurney,  muscle-splitting  or  gridiron  incision  is  placed 
entirely  external  to  the  semilunar  line,  dividing  the  oblique  and 
transverse  abdominal  muscles  in  the  line  of  their  fibres.  The  skin 
incision  may  be  made  in  any  desired  direction,  preferably  in  the  line 
of  the  fibres  of  the  external  oblique.  The  aponeurosis  of  this  muscle 
is  then  exposed,  nicked  with  the  knife,  seized  with  two  pairs  of  for- 
ceps and  torn  in  the  direction  of  its  fibres,  exposing  the  fibres  of  the  in- 
ternal oblique  beneath  its  delicate  overlying  fascia  which  in  this 
situation  run  nearly  transversely.  This  muscle  and  the  transversalis 
(with  its  delicate  overlying  fascia)  are  then  likewise  separated  in  the 
direction  of  their  respective  fibres,  exposing  the  transversalis  fascia, 
preperitoneal  fat  and  peritoneum.  These  structures  are  then 
divided  with  the  usual  precautions,  in  the  line  of  the  external  oblique 
fibres.  A  wound  thus  made  does  not  divide  any  of  the  abdominal 
nerves,  which  fact  is  evidently  a  strong  recommendation  in  favor  of 
such  an  operation;  but  the  great  difficulty  is  to  select  the  proper  case. 
Although  it  is  understood  that  this  operation  is  particularly  intended 
for  the  interval  cases,  yet  many  of  these  are  quite  complicated,  and 
many  require  enlargement  of  the  incision.  This  is  best  accom- 
plished by  making  a  second  cut  upward  along  the  semilunar  line 
from  the  inner  angle  of  the  McBurney  incision.  I  seldom  use  this 
incision  in  the  case  of  females  since  it  is  always  advisable  to  palpate 
the  internal  genitalia  and  if,  as  occasionally  happens,  a  condition 
requiring  operation  is  found  it  is  more  difficult  to  enlarge  the  Mc- 
Burney incision  for  satisfactory  pelvic  work.  Usually  it  will  be  better 
to  close  the  McBurney  opening  and  make  a  separate  rectus  incision. 

An  incision  similar  to  that  originally  employed  by  Hancock,  is 
a  good  one  in  abscess  cases,  where  the  mass  is  close  to  the  anterior 


Treatment  285 

superior  iliac  spine  or  where  the  appendix  can  be  distinctly  located 
in  this  position.  This  incision  is  in  the  line  of  the  fibres  of  the 
external  oblique,  about  half  an  inch  above  the  outer  extremity  of 
Poupart's  ligament.  There  are  divided,  the  skin,  superficial 
fascia,  aponeurosis  of  the  external  oblique,  a  thin  layer  of  fascia 
covering  the  internal  oblique,  the  internal  oblique,  branches  of  the 
deep  circumflex  iliac  vessels,  a  second  thin  layer  of  fascia  overlying 
the  transversalis  muscle,  and  the  transversalis  muscle;  the  cut  edges 
of  the  muscle  on  the  inner  side  of  the  wound  are  then  well  retracted, 
and  the  transversalis  fascia  preperitoneal  fat  and  peritoneum  are 
divided  well  down  to  the  outer  side  of  the  caecum.  This  incision  is 
particularly  adapted  to  those  cases  of  appendiceal  abscess  where  the 
patient  is  in  no  fit  condition  to  withstand  a  complete  operation,  and 
where  drainage  of  the  abscess  is  all  that  is  desired.  In  such  cases 
it  is  frequently  impossible  to  recognize  the  various  layers  of  the 
abdominal  wall,  since  they  are  frequently  infiltrated  and  matted 
together.  Where  the  appendix,  however,  is  found  well  toward 
the  crest  of  the  ilium  it  can  be  readily  removed  through  this  in- 
cision, with  little  danger  of  infecting  the  peritoneal  cavity,  as  the 
limiting  adhesions  constituting  the  inner  wall  of  the  abscess  cavity, 
are  not  broken  down.  The  division  of  the  fibres  of  the  internal 
oblique  and  transversalis  muscles  which  is  necessitated  by  this 
incision,  renders  the  subsequent  formation  of  a  ventral  hernia  more 
likely  when  drainage  is  employed,  but  this  is  a  small  matter  com- 
pared with  the  recovery  of  the  patient,  which  is  much  more  apt  to 
follow  the  use  of  an  incision  allowing  of  rapid  completion  of  the 
operation  and  direct  drainage.  This  is  an  incision  which  I  never 
employ  unless  we  have  every  evidence  that  there  is  a  well-local- 
ized abscess  and  that  the  incision  will  enable  the  operator  to  reach 
it  extra-peritoneally. 

Still  another  incision  is  occasionally  useful.  This  is  an  oblique 
incision  passing  from  above  the  iliac  spine  back  into  the  loin  space, 
in  the  direction  of  the  fibres  of  the  external  oblique.  It  is  particu- 
larly adapted  to  suppurative  cases  in  which  the  appendix  lies  to  the 
outer  side  of  the  caecum  and  colon,  running  northwest;  by  this  incision 
better  access  is  gained  to  the  site  of  the  infected  appendix,  and  there 
is  less  likelihood  of  infecting  the  general  peritoneum.  The  great 
difficulty,  however,  in  all  these  cases,  is  to  determine,  before  the 


286  Appendicitis 

abdomen  is  opened,  just  where  the  appendix  lies ;  and  unless  there  is 
pretty  good  evidence  of  its  running  northwest  in  the  right  lumbar 
region  it  will  not  be  advisable  to  employ  this  incision,  although 
Hancock's  incision,  just  described,  may  often  be  extended  upward 
into  this  oblique  incision  with  the  utmost  advantage.  When  drain- 
age is  used  the  development  of  ventral  hernia  is  to  be  anticipated, 
and  a  secondary  operation  will  frequently  be  required  for  its  cure. 

In  making  any  of  these  incisions,  haemorrhage  should  be  checked 
before  the  peritoneum  is  opened.  Unless  some  vessel  large  enough 
to  have  a  name — such  as  the  deep  epigastric  or  circumflex  iliac — be 
divided,  it  is  at  times  sufficient  to  clamp  the  bleeding  point  for  a  few 
minutes,  when  the  bleeding  will  be  found  to  have  been  arrested. 
It  is  always  safer,  however,  to  ligate  every  bleeding  point. 

It  will  be  convenient  first  to  describe  the  method  to  be  employed 
in  removing  the  appendix  in  cases  where  pus  is  known  to  be  absent, 
and  subsequently  to  describe  the  treatment  of  suppurative  cases. 

Technic  in  Clean  Cases. — ^The  surgeon  may  either  pull  forth 
the  presenting  bowel,  which  is  usually  the  caecum,  through  the  wound, 
and  trace  one  of  its  longitudinal  bands  down  to  the  base  of  the  appen- 
dix, whose  position  is  thus  determined;  or,  if  his  skill  and  tactile 
sense  be  sufficient  for  the  purpose,  he  may  introduce  one  or  two 
fingers  into  the  wound,  isolate  the  appendix  between  them,  and 
withdraw  it  from  the  abdomen  at  once,  without  first  locating  the 
caecum.  The  latter  makes  a  very  brilliant  operation,  but  the  former 
plan  is  less  apt  to  miscarry.  In  trying  to  find  the  appendix  by  the 
sense  of  touch,  the  best  manoeuvre  is  to  locate  the  external  iliac 
artery,  which  is  readily  found  by  its  pulsation,  and  then  to  run  the 
finger  up  along  its  course  until  it  is  arrested  by  the  lower  end  of  the 
mesentery  and  the  caecum,  in  which  neighborhood  the  appendix  may 
usually  be  found;  by  hooking  the  finger  around  it,  it  may  then  be 
delivered  from  the  abdomen.  My  own  practice  in  clean  cases  is 
not  to  retract  the  margins  of  the  wound  when  the  peritoneal  cavity 
has  been  opened,  but  to  introduce  the  index-finger  and  locate  the 
caecum  by  the  sense  of  touch,  when,  with  a  pair  of  dissecting  forceps 
which  are  passed  along  the  finger  to  the  caecum,  it  is  grasped  carefully 
and  drawn  into  the  wound.  It  is  then  grasped  with  the  finger  and 
thumb,  and  delivered  through  the  abdominal  wound  until  the  base 
of  the  appendix  is  seen.     If  the  wound  is  small  and  the  caecum  large, 


Treatment  287 

care  should  be  taken  not  to  deliver  too  much  of  the  caecum  at  one 
time,  but  to  replace  some  before  delivering  more.  If  this  matter 
is  not  attended  to  at  the  proper  time,  the  surgeon  may  be  mortified 
to  find,  after  removing  the  appendix,  that  he  must  enlarge  the 
abdominal  wound  to  enable  him  to  reduce  the  caecum,  which  soon 
becomes  congested  when  constricted  by  a  small  wound.  I  have 
seen  one  case  in  which  efforts  to  reduce  the  caecum  through  too  small 
a  wound  caused  the  separation  of  the  ligature  from  the  meso-appen- 
dix,  with  the  result  that  the  patient  nearly  lost  her  life  from  intra- 
peritoneal haemorrhage  before  the  accident  was  discovered  by  the 
constitutional  symptoms  of  concealed  haemorrhage.  Where  the 
great  omentum  or  terminal  coils  of  small  intestine  interfere  with  the 
free  delivery  of  the  caecum  and  appendix  it  is  my  practice  to  intro- 
duce one  or  more  gauze  pads  and  in  this  manner  make  the  manipu- 
lation easier  and  less  likely  in  the  presence  of  infection  to  damage 
the  surrounding  healthy  peritoneum.  If  the  caecum  and  appendix 
do  not  lift  out  easily,  in  other  words,  are  bound  down  by  adhesions, 
I  at  once  enlarge  the  wound  as  it  is  not  safe  to  make  traction  to  any 
degree,  for  fear  that  adhesions  may  be  torn  and  infection  liberated. 
There  is  also  risk  of  tearing  a  subcaecal  vein  by  too  much  traction 
upon  the  caecum,  an  accident  that  has  occurred  once  in  my  own 
practice  and  which  necessitated  a  secondary  operation  for  the  result- 
ing haemorrhage. 

When  the  appendix  is  delivered  a  haemostatic  forceps  should  be 
placed  upon  its  base  and  one  upon  the  mesentery  near  the  tip.  Now 
lifting  the  appendix  by  the  forceps  the  mesentery  is  spread  out 
and  may  be  perforated  in  a  bloodless  space  near  the  base  of  the 
appendix  by  a  haemostat  carrying  a  fine  silk  or  chromic  catgut  suture. 
The  haemostat  is  withdrawn  and  the  meso-appendix  ligated.  Now 
releasing  the  haemostat  originally  applied  to  the  tip  of  the  mesentery 
the  surgeon  grasps  the  appendix  with  dissecting  forceps  and  cuts 
the  mesentery  along  its  appendiceal  attachment  freeing  the  appendix 
to  its  base.  A  catgut  suture  is  tied  around  the  appendix  about 
one-fourth  inch  distal  to  the  junction  of  the  appendix  with  the 
caecum.  A  purse-string  suture  of  fine  Pagenstecher  linen  thread  is 
then  placed  in  the  sero-muscular  coat  of  the  caecum  around  the  base 
of  the  appendix  and  at  a  distance  of  about  one-half  inch.  This  is 
allowed  to  lie  while  the  surgeon  picks  up  the  appendixby  the  suture 


288  Appendicitis 

on  its  base,  which  has  been  left  long  for  this  purpose.  A  piece  of 
gauze  is  placed  around  the  appendix  to  guard  further  against  con- 
tamination of  the  field  of  operation.  With  a  pair  of  scissors  curved 
on  the  flat  the  appendix  is  now  amputated  between  the  forceps  and 
the  ligature  and  quickly  removed;  the  mucous  membrane  of  the 
appendix  is  excised  and  the  stump  charred  with  the  cautery.  It  is 
better  technic  to  amputate  the  appendix  with  the  cautery.  If  no 
cautery  is  at  hand  it  will  suffice  to  touch  the  stump  with  pure 
carbolic  acid  and  then  with  alcohol,  the  excess  of  which  should  be 
absorbed  by  a  gauze  sponge.  By  cultures  made  from  stumps  treated 
in  both  ways  I  have  found  that  the  actual  cautery  is  the  surest  means 
of  sterilization.  Now  discarding  the  gauze  which  has  been  used  to 
protect  the  field,  an  assistant  grasps  the  stump  with  a  pair  of  dis- 
secting forceps  and  the  surgeon  takes  up  the  ends  of  the  purse- 
string  suture.  The  long  ends  of  the  appendix  ligature  are  cut  near 
the  knot,  the  stump  of  the  appendix  is  invaginated  into  the  caecum 
and  the  purse-string  is  tied,  completing  the  removal  of  the  appendix. 
It  should  be  borne  in  mind  that  each  instrument  that  is  used  to 
touch  the  cut  surface  or  stump  should  be  discarded  at  once.  Always 
survey  the  ligature  on  the  meso-appendix  at  the  completion  of  the 
operation  before  closing  the  abdomen.  Being  assured  that  hsemosta- 
sis  is  complete  the  caecum  is  reposited  and  the  wound  closed  as 
hereafter  described. 

Certain  variations  from  this  simple  technic  may  be  rendered 
necessary  by  conditions.  When  the  meso-appendix  is  especially 
large  and  fat  it  is  safer  to  ligate  it  in  sections.  When  the  meso- 
appendix  is  absent  or  the  appendix  tied  down  by  adhesions  it  is 
necessary  to  free  it  first,  clamping  the  bleeding  points  as  they  appear 
and  ligating  later.  If  the  meso-appendix  be  short  and  distorted  it 
may  be  clamped  in  sections  and  the  appendix  freed  little  by  little. 
The  clamps  should  be  tied  off  before  removal  of  the  appendix  to 
avoid  displacement  and  also  the  dissemination  of  infection  if  con- 
tamination should  accidentally  occur  during  the  treatment  of  the 
stump. 

Occasionally  we  find  an  appendix  so  bound  down  by  adhesions 
at  its  tip  that  only  the  base  can  be  delivered.  In  these  cases  the 
base  must  be  tied  off  as  described  and  the  appendix  dissected  free 
from  base  to  tip,  bleeding  vessels  being  clamped  and  ligated  as  cut. 


Treatment  289 

When  any  part  of  the  appendix  Hes  beneath  the  serosa  of  the  caecum, 
as  is  sometimes  the  case,  the  bowel  should,  when  possible,  have  its 
serous  covering  restored  by  means  of  Lembert  sutures  in  order 
to  lessen  the  probability  of  the  formation  of  adhesions. 

Various  modifications  of  the  treatment  of  the  stump  are  in  use. 
A  few  surgeons  drop  the  stump  with  or  without  treatment  after 
disinfection.  I  condemn  this  practice  as  I  have  seen  intestinal 
obstruction  from  a  band  proceeding  from  a  stump  replaced  in  this 
manner.  Dawbarn's  method  of  simple  invagination  into  the  caecum 
without  ligation  I  have  abandoned  after  having  several  cases  of 
bleeding  more  or  less  severe  from  the  cut  surface.  Complete 
excision  of  the  base  of  the  appendix  and  repair  of  the  resulting  hole 
in  the  caecum  is  unnecessary  and  more  likely  to  cause  contamination 
of  the  peritoneum  and  the  abdominal  wound.  The  various  sutures 
in  use  for  covering  over  the  stump  are  not  worth  discussion  since 
they  possess  in  common  the  principle  of  burying  the  stump  in  order 
to  leave  no  raw  surface  to  invite  the  formation  of  adhesions. 

Technic  in  Suppurative  Cases. — Since  the  success  of  the 
operative  treatment  of  appendicitis  complicated  by  pus  formation 
depends  largely  upon  a  knowledge  of  the  anatomical  varieties  of 
peri-appendicular  abscess,  as  well  as  upon  a  complete  comprehension 
of  the  safest  method  of  evacuating  the  pus  and  removing  the  appen- 
dix without  infecting  the  general  peritoneal  cavity,  a  brief  description 
of  the  operative  technic  to  be  practised  in  each  instance  may  be 
given. 

Depending  upon  the  location  of  the  pus,  peri-appendicular 
abscess  is  met  with  as  one  of  five  varieties:  First,  and  in  my  experi- 
ence the  most  common,  is  that  in  which  the  collection  lies  below 
or  to  the  outer  side  of  the  caecum  beneath  the  anterior  parietal 
peritoneum,  being  confined  by  the  caecum,  coils  of  small  intestine, 
the  omentum,  the  parietal  peritoneum,  and  inflammatory  exudate; 
second,  that  in  which  the  collection  of  pus  is  located  behind  the 
caecum,  to  the  outer  side  of  or  behind  the  caecum  and  ascending 
colon,  or  between  the  layers  of  the  ascending  meso-colon,  in  the 
retro-peritoneal  cellular  tissue;  third,  that  in  which  the  abscess  lies 
in  the  pelvis,  being  usually  entirely  shut  ofT  from  the  general  perit- 
oneal cavity;  fourth,  that  in  which  the  collection  of  pus  is  located 
near  the  median  line  of  the  abdomen  and  to  the  median  side  of  the 
19 


290  Appendicitis 

caecum;  fifth,  that  in  which  the  pus  is  free  in  the  general  peritoneal 
cavity. 

In  dealing  with  any  variety  of  circumscribed  peri-appendicular 
suppuration,  it  is  important  to  protect  the  general  peritoneal  cavity 
from  infection.  As  a  rule  it  is  only  when  the  abscess  is  of  the  first 
variety  described  above,  that  it  can  be  reached  and  evacuated  with- 
out first  traversing  the  free  peritoneal  cavity.  Only  a  few  cases  of 
the  second  variety  can  be  treated  in  this  manner.  Hence  it  becomes 
necessary  in  almost  all  suppurative  cases  to  work  through  a  coffer- 
dam of  gauze.  The  correct  disposition  of  this  gauze  requires  the 
utmost  skill.  It  may  be  laid  down  as  a  rule  that  in  endeavoring 
to  exclude  the  intestines  from  the  field  of  operation  the  disposition 
of  the  gauze  must  be  commenced  from  the  extremities  of  the  wound, 
and  proceed  to  the  centre;  by  placing  a  gauze  pack  first  in  the  centre 
of  the  wound,  the  intestines  will  prolapse  around  both  sides  of  it, 
thus  increasing  the  difficulty  of  excluding  them  from  the  operative 
area.  Another  good  rule  is  never  to  proceed  with  an  operation  in 
which  adhesions  are  discovered  until  gauze  has  been  so  disposed  as 
to  protect  the  general  peritoneal  cavity  from  the  rupture  of  an  abscess 
which  may  be  concealed  by  adhesions.  The  gauze  should  not  be 
carried  into  the  peritoneal  cavity  further  than  is  necessary  and  its 
introduction  should  be  accomplished  with  great  gentleness  and  care 
to  avoid  as  far  as  possible  injury  to  the  endothelium  which  pre- 
disposes not  only  to  infection  but  to  the  formation  of  adhesions. 

In  dealing  with  any  variety  of  peri-appendicular  suppuration 
which  must  be  treated  transperitoneally,  as  soon  as  the  peritoneum 
is  incised  the  general  peritoneal  cavity  should  be  protected  from 
infection  by  the  proper  disposition  of  gauze  pads.  The  first  pad 
to  be  introduced  should  pass  from  the  right  iliac  fossa  into  the 
pelvis,  and  will  hold  the  small  bowel  away  from  the  lower  angle  of 
the  wound.  Then  as  many  more  pads  as  may  be  required  are  to 
be  placed  from  below  upward  until  the  entire  median  side  of  the 
wound,  as  well  as  its  lower  extremity,  is  lined  with  gauze.  Finally, 
the  upper  limit  of  the  field  of  operation  must  be  protected  by  gauze. 
The  abscess  should  then  be  opened  by  breaking  through  the  layer 
of  exudate  that  forms  its  outer  wall,  or,  if  the  abscess  be  of  the  second 
variety,  through  the  outer  layer  of  the  ascending  meso-colon.  The 
abscess  cavity  should  be  wiped  out  with  dry  gauze.     The  appendix 


Treatment 


291 


should  then  be  located  and  removed.  When  the  appendix  is  gan- 
grenous or  involved  in  the  abscess  the  stump  should  not  be  invagin- 
ated  into  the  caecum  but  after  ligation  with  chromicized  catgut  it 
should  be  sterilized  with  the  cautery  or  carbolic  acid  and  alcohol 
and  dropped  back  without  any  attempt  to  bury  it.  The  catgut  is 
less  liable  to  form  a  dead  ligature  than  silk  or  other  non-absorbable 
material.  Drainage  of  the  abscess  cavity  is  essential.  If  it  has  not 
been  necessary  to  enter  the  general  abdominal  cavity  it  will  suffice 
to  insert  a  rubber  tube  of  large  calibre,  or  strip  of  folded  rubber 
dam  or  wisps  of  gauze.  In  fact  any  device  which  will  maintain  a 
free  avenue  of  discharge  through  the  wound  and  avoid  all  damming 
back  of  the  exudation  will  prove  satisfactory.  Gauze  should  never 
be  packed  tightly  into  the  cavity,  and  if  used  alone  should  be  cau- 
tiously loosened  on  the  second  or  third  day  to  make  sure  that  it 
is  not  acting  as  a  plug.  It  is  more  satisfactory  in  most  cases  to 
use  a  rubber  tube  either  alone  or  in  conjunction  with  gauze.  When 
the  abscess  is  not  of  large  size  folded  strips  of  rubber  dam  are  a  most 
excellent  form  of  drainage  as  they  provide  for  the  free  exit  of  the 
secretions  and  at  the  same  time  permit  more  rapid  collapse  and 
obliteration  of  the  cavity. 

When  the  general  peritoneal  cavity  has  been  opened,  in  addition 
to  draining  the  infected  area  it  becomes  necessary  to  wall  off  the 
adjacent  intestines  and  omentum.  Nothing  will  accomplish  this 
so  satisfactorily  as  gauze.  In  all  my  work  I  use  plain  moist  sterile 
gauze  since  it  answers  every  purpose  and  is  unattended  by  any  of 
the  disagreeable  or  dangerous  features  of  gauze  impregnated  with 
iodoform  or  other  antiseptic  agent.  The  purpose  of  gauze  in  this 
instance  is  not  only  to  provide  capillary  drainage  but  to  provoke 
adhesions  between  the  adjacent  viscera,  thus  establishing  a  tract 
shut  off  from  the  peritoneal  cavity  and  placing  the  bottom  of  the 
abscess  in  free  communication  with  the  surface.  On  account  of 
the  danger  attendant  upon  the  formation  of  intestinal  adhesions  it 
should  be  our  aim  not  to  excite  denser  or  more  numerous  adhesions 
than  are  necessary.  An  excess  of  gauze  therefore  should  not  be 
used  and  often  it  will  be  possible  to  interpose  between  it  and  the 
healthy  intestines  a  surrounding  layer  of  rubber  dam  which  has  less 
tendency  to  excite  excessive  granulations  upon  the  surface  of  the 
bowels.     This  also  facilitates  removal  of  the  gauze  in  addition  to 


2g2  Appendicitis 

making  it  less  painful.  This  is  the  principle  of  the  familiar  "cigar- 
ette" drain,  which,  as  usually  made,  is  too  small  to  accomplish 
drainage  and  is  inefficient  in  establishing  a  drainage  tract.  When 
the  septic  focus  is  very  small  and  the  exudation  slight,  in  other 
words  when  there  is  but  little  to  drain  the  cigarette  drain  will  be 
satisfactory.  When  the  cavity  is  large,  foul,  its  walls  rough  and 
friable  and  it  is  evident  that  drainage  must  be  free,  a  rubber  tube 
should  always  be  used  and  this  may  with  advantage  be  placed  in 
the  centre  of  the  nest  of  gauze  reaching  to  the  bottom  of  the  abscess 
cavity.     It  should  be  fixed  to  the  skin  by  a  fine  suture. 

In  practically  all  suppurative  cases  I  pass  a  glass  tube  into 
the  pelvis  and  aspirate  to  determine  whether  a  purulent  collection 
is  present.  If  so  the  tube  is  allowed  to  remain.  Also,  when  it  is 
feared  from  the  nature  of  the  case  that  the  pelvic  cavity  has  been  or  is 
likely  to  h^  contaminated  from  the  manipulation  in  the  arrange- 
ment of  the  drainage  I  consider  it  a  precautionary  measure  to 
leave  a  tube  in  the  pelvis,  which  may  be  removed  in  twenty-four  or 
thirty-six  hours  if  the  fluid  aspirated  therefrom  is  scanty,  clear  and 
straw  colored.  I  do  not  allow  a  glass  tube  to  remain  longer  than 
thirty-six  hours  being  influenced  by  the  assertion  that  they  are  more 
likely  to  cause  necrosis  of  the  bowel  or  acute  angulation  resulting 
in  obstruction  than  tubes  of  rubber,  though  my  personal  experience 
with  glass  drainage  does  not  bear  this  out.  If  the  character  of  the 
drainage  indicates  that  it  is  unwise  to  discontinue  the  drain  a  small 
rubber  tube  may  be  passed  down  the  lumen  of  the  glass  tube  and 
the  latter  withdrawn. 

The  drains  should  emerge,  as  a  rule,  through  that  part  of  the 
wound  nearest  the  abscess  cavity;  usually  this  will  be  through  the 
lower  extremity  of  the  abdominal  opening.  In  some  cases  the 
wound  should  be  left  entirely  open ;  usually  it  may  be  closed  in  part. 
If  an  oblique  incision  passing  into  the  flank  has  been  employed 
the  drainage  should  emerge  from  its  outer  or  posterior  extremity. 
After  the  lapse  of  four  or  five  days,  or  even  longer,  the  drainage 
may  be  removed,  only  enough  being  replaced  to  insure  drainage  and 
the  abdominal  wound  allowed  to  heal  gradually  by  granulation. 
A  fuller  discussion  of  the  subsequent  management  of  these  cases 
will  be  found  under  the  heading  of  After-treatment. 

In  the  treatment  of  the  first  variety  of  peri-appendicular  abscess, 


Treatment  293 

the  collection  of  pus  is  often  opened  immediately  upon  carrying 
the  incision  through  the  parietal  peritoneum.  It  is  for  these  cases 
that  I  prefer  the  incision  close  to  the  iliac  crest  and  Poupart's 
ligament,  since  the  abscess  usually  points  in  this  situation.  I 
am  opposed  to  the  practice  of  opening  abscesses  transperitoneally 
when  it  is  possible  to  open  into  them  directly  without  exposing  the 
general  peritoneal  cavity  to  infection.  Certainly  if  nature  has 
succeeded  in  localizing  the  inflammatory  process  to  an  isolated 
area,  it  must  be  considered  rash  surgery  to  open  avenues  of  in- 
fection to  the  free  peritoneum.  Not  every  abscess  is  large  enough 
or  so  favorably  situated  as  to  permit  of  extra-peritoneal  attack.  In 
these  cases  the  risk  of  infecting  the  peritoneal  cavity  by  the  trans- 
peritoneal operation  must  be  accepted  and  while  the  great  majority 
of  these  cases  recover,  yet  their  convalescence  is  apt  to  be  more 
stormy,  the  risk  of  obstruction  greater,  and  occasionally  general 
peritonitis  ensues.  The  fact  that  most  of  these  cases  recover 
should  not  in  my  opinion  inspire  the  surgeon  with  the  belief  that 
it  is  a  safe  procedure  and  one  to  be  uniformly  adopted  in  all  cases  of 
abscess.  When  a  peri-appendicular  abscess  is  large,  well  defined 
and  abutting  upon  the  parietes  at  a  safe  point  of  attack  it  should 
always  be  opened  extra-peritoneally.  Irrigation  in  this  variety  of 
abscess  is  attended  by  danger  on  account  of  the  delicacy  of  the 
confining  wall,  which  renders  dissemination  of  infectious  material  a 
matter  very  easy  of  accomplishment.  Evacuation  of  the  abscess  is 
ordinarily  effected  without  risk  of  infecting  the  peritoneum,  since 
the  incision  that  corresponds  to  the  most  prominent  part  of  the 
swelling,  or,  if  no  swelling  be  present,  to  the  point  over  the  involved 
region  most  tender  to  pressure,  comes  directly  down  upon  the 
purulent  collection.  This  variety  of  abscess  can  usually  be  said  to 
be  present  when  the  abdominal  muscles  along  the  line  of  the  incision 
are  found  to  be  the  seat  of  inflammatory  cedema  and  infiltration. 
If  the  muscles  are  not  thus  affected,  the  infiltrate  will  be  found 
in  the  transversalis  fascia  and  the  preperitoneal  fat.  The  pus  is 
readily  disposed  of  by  mopping  with  pieces  of  gauze.  If  the 
can  be  located  and  removed  with  a  minimum  risk  of  spreading  the 
infection  it  should  be  done. 

In  this  first  variety  of  abscess  it  frequently  happens  that  the 
collection  of  pus  is  not  confined  at  its  lower  end,  but  is  in  communica- 


294  Appendicitis 

tion  with  the  pelvis.  I  make  it  a  rule,  therefore,  to  pass  a  glass 
drainage  tube  down  to  the  floor  of  the  pelvis,  to  determine  definitely 
the  presence  or  absence  of  pus.  On  many  occasions  when  operating 
upon  this  variety  of  peri-appendicular  suppuration,  I  have  evacuated 
no  more  than  a  dram  or  two  of  pus  upon  opening  the  peritoneum; 
but  upon  passing  a  drainage  tube  into  the  pelvis,  as  much  as  half  a 
pint  of  pus  has  escaped. 

The  second  variety  of  appendiceal  abscess  when  it  is  large 
and  evidently  pointing  in  the  loin  may  be  attacked  directly  by  a 
loin  incision  and  evacuated  extra-peritoneally  in  the  same  manner 
as  is  indicated  for  the  first  variety.  At  times  the  situation  of  the 
abscess  cannot  be  determined  clearly  before  the  abdominal  cavity 
has  been  opened.  Even  in  such  an  event,  in  abscess  of  this  variety 
I  would  prefer  to  close  the  anterior  incision  and  drain  through  an 
extra-peritoneal  incision  in  the  loin.  Extremely  small  and  encapsu- 
lated abscesses  in  the  subcaecal  fossa  will  naturally  be  opened  through 
an  anterior  incision,  but  abscesses  of  any  size  which  have  as  their 
posterior  wall  the  cellular  tissues  posterior  and  lateral  to  the  caecum 
or  ascending  colon  should  invariably  be  opened  extra-peritoneally. 
The  appendix  often  can  be  found  and  removed.  It  is  seldom 
necessary  to  leave  the  appendix  and  every  effort  compatible  with  the 
general  safety  of  the  patient  should  be  made  to  find  it.  I  do  not 
agree,  however,  with  those  surgeons  who  advise  never  to  leave  the 
appendix.  In  a  certain  small  proportion  of  cases  extensive  damage 
may  be  done  to  the  friable  bowel  by  too  active  search  and  it  is  better 
judgment  to  desist  and  accept  the  chance  of  recurrence  which  is 
present  when  the  organ  has  not  been  removed,  or  better,  to  remove 
the  appendix  at  a  second  operation  after  healing  has  taken  place. 
Drainage  is  established  in  accordance  with  the  principles  previously 
indicated. 

In  operating  upon  the  third  variety  of  peri-appendicular  abscess 
the  abdomen  is  usually  opened  by  an  incision  in  the  right  rectus, 
the  inner  margin  of  the  wound  raised  by  retractors  and  the  general 
peritoneal  cavity  well  walled  off  from  the  pelvic  cavity  with  gauze 
before  an  attempt  is  made  to  treat  the  appendix  or  the  abscess. 
The  gauze  is  most  readily  disposed  by  carrying  one  or  more  pads 
across  the  intestines  toward  the  left  side  and  then  successively  pack- 
ing gauze  from  this  across  the  median  line  and  then  above  the  caecum 


Treatment  295 

on  the  right  side.  In  this  way  the  wall  of  pads  isolates  the  general 
peritoneal  cavity  from  the  pelvis  and  not  only  gives  additional 
room  to  work  but  prevents  the  extension  of  pus  when  the  abscess 
is  opened.  After  the  proper  disposition  of  gauze  the  finger  should 
be  carried  over  the  brim  of  the  true  pelvis  down  into  the  collection 
of  pus,  and,  with  the  finger  as  a  guide,  a  glass  drainage  tube  should 
be  introduced.  Through  this  the  pus  may  be  evacuated.  The 
appendix  may  then  be  sought  and  removed.  If  the  abscess  is  very 
small  and  accessible  a  glass  or  rubber  tube  may  be  the  only  drainage 
required.  Usually  it  will  be  best  to  place  round  the  tube  one  or  more 
gauze  drains  in  order  to  secure  isolation  of  the  healthy  peritoneum 
from  the  abscess  and  drainage  tract.  The  tube,  if  of  glass,  should 
be  removed  in  thirty-six  to  forty-eight  hours  and  a  small  one  of  rubber 
substituted.  This  may  be  withdrawn  gradually  depending  on  the 
amount  of  suppuration  present.  The  gauze  should  not  be  tampered 
with  for  at  least  four  days  or  more,  when  it  may  be  gently  loosened, 
but  not  withdrawn  until  it  may  be  done  without  using  undue  force. 
The  upper  portion  of  the  abdominal  wound  can  usually  be  closed  at 
the  time  of  operation.  The  drainage  tract  must  be  allowed  to  heal 
by  granulation. 

If  it  were  not  possible  to  exclude  so  thoroughly  the  area  of  opera- 
tion, it  would  no  doubt  be  safer  to  evacuate  the  abscess  through  the 
vagina  or  the  rectum,  the  case  then  being  analogous  to  the  treatment 
recommended  for  the  second  variety  of  peri-appendicular  suppura- 
tion, by  evacuation  through  the  loin;  with  the  important  exception, 
however,  that  in  the  latter  the  appendix  can  frequently  be  success- 
fully removed  through  the  lumbar  incision  at  the  first  operation, 
whereas  in  the  case  of  pelvic  abscess  the  appendix  could  not  possibly 
be  removed  through  the  vagina  or  rectum.  In  selected  cases  in 
adults  this  method  of  evacuation  will  give  good  results.  It  should 
be  attempted  only  when  there  are  the  most  definite  indications  of  a 
large  pelvic  collection  which  is  pointing  in  the  region  of  the  rectum 
or  cul-de-sac  and  the  upper  abdomen  is  entirely  clear.  Manifestly 
it  is  difficult  to  be  certain  of  these  conditions.  In  children  the  vagina 
should  never  be  used  to  drain  a  pelvic  abscess  and  the  rectum  is  less 
available  than  in  adults  on  account  of  its  small  calibre. 

In  the  fourth  variety  of  peri-appendicular  abscess  the  collection 
of  pus  lies  to  the  inner  side  of  the  caecum,  and  the  confining  wall  is 


296  Appendicitis 

made  up  of  the  caecum,  appendix,  small  intestine,  mesentery,  omen- 
tum, and  possibly  the  sigmoid  flexure.  At  times,  also,  the  purulent 
collection  is  found  beneath  the  mesentery  of  the  terminal  portion 
of  the  small  intestines.  These  cases  are  among  the  most  fatal 
of  all  varieties  of  circumscribed  peri-appendicular  suppuration 
and  the  surgeon  is  indeed  fortunate  if  he  can  open  into  the  abscess 
cavity  without  first  traversing  the  peritoneal  cavity.  If,  however, 
on  making  his  incision  in  the  usual  place,  he  finds  adhesions  to  the 
parietal  peritoneum  and  evidence  of  inflammation  in  a  region  which 
makes  it  probable  that  this  form  of  abscess  is  present,  it  may  be 
necessary  for  him  to  make  a  second  incision  toward  the  median  line 
of  the  abdomen,  to  insure  the  proper  disposition  of  gauze  for  the 
protection  of  the  general  peritoneal  cavity.  The  further  operative 
procedures  are  similar  to  those  already  detailed. 

The  treatment  of  the  fifth  variety  of  suppurative  or  diffuse  purulent 
peritonitis  has  been  discussed  in  part  in  connection  with  the  question 
of  the  time  for  operation.  When  diffuse  peritonitis  is  widespread  as 
previously  indicated  operation  should  be  deferred  until  localization 
has  taken  place.  The  operative  treatment  then  becomes  the  same 
as  detailed  in  the  discussion  of  the  several  varieties  of  abscess.  In 
the  earlier  stages  of  unconfined  peritonitis,  the  treatment  may  consist 
solely  in  the  removal  of  the  appendix.  The  judgment  and  experi- 
ence of  the  operator  must  be  called  upon  to  decide  upon  the  necessity 
for  drainage.  We  formerly  drained  too  freely  and  have  learned 
that  the  peritoneum  can  care  for  an  amazing  amount  of  infection 
without  help.  The  majority  of  cases  which  show  only  turbid  or 
slightly  flaky  fluid  exudate  may  be  closed  completely  with  the 
assurance  of  recovery.  When  the  pus  is  foul  or  vicious  in  appearance 
it  is  safer  to  insert  a  tube  into  the  pelvis  which  may  be  removed  in 
twenty-four  to  seventy-two  hours  depending  upon  the  amount  and 
character  of  the  drainage  which  takes  place. 

Few  cases  of  this  variety  will  be  encountered  if  the  plan  previously 
laid  down  for  the  treatment  of  diffusing  peritonitis  be  followed,  for 
in  this  way  diffusing  peritonitis  is  converted  to  circumscribed  perit- 
onitis. The  early  cases  which  show  a  free,  more  or  less  purulent, 
effusion  in  the  neighborbood  of  the  appendix  or  in  the  pelvis  may  or 
may  not  require  drainage.  If  very  turbid,  flaky  or  foul  a  tube  should 
be  inserted  into  the  pelvis  to  provide  for  drainage.     But  I  drain 


Treatment  297 

much  less  frequently  than  formerly  in  this  class  and  whereas  I  once 
adopted  the  rule  "when  in  doubt  drain"  I  am  now  more  inclined  to 
advise  "when  in  doubt  do  not  drain." 

If  the  appendix  or  its  bed  is  gangrenous,  or  a  weakened  portion 
of  bowel  exists  a  wick  of  gauze  or  folded  rubber  dam  should  be 
placed  in  contact  with  this  area  and  brought  out  through  the  wound. 
When  free  purulent  exudate  is  present  in  the  peritoneal  cavity  a  glass 
tube  should  always  be  placed  in  the  pelvis  before  the  operation  is 
concluded  in  order  to  test  by  aspiration  and  inspection  the  amount 
and  character  of  the  fluid  which  has  gravitated  into  the  pelvis.  If 
it  is  decided  not  to  drain  this  may  at  once  be  removed.  In  other 
respects  the  operative  treatment  of  the  early  stages  of  diffuse  perit- 
onitis does  not  differ  materially  from  the  operation  practised  when 
the  disease  is  confined  entirely  to  the  appendix.  I  have  abandoned 
irrigation  of  the  abdominal  cavity  with  resulting  reduction  in 
mortality. 

Not  infrequently  conditions  are  found  in  the  abdomen  which 
complicate  the  operation. 

These  circumstances  may  be  due  either  to  conditions  existing 
before  the  appendix  became  inflamed,  or  to  changes  produced  in  the 
progress  of  the  disease.  Among  those  existing  before  the  onset 
of  the  appendicitis,  miusual  positions  of  the  appendix  are  the  most 
important,  often  causing  considerable  difficulty  in  the  removal  of 
the  organ.  I  have  frequently  encountered  cases  in  which  the  ana- 
tomical conditions  were  such  that  at  first  sight  the  organ  might 
be  supposed  absent.  In  these  cases  the  appendix  was  usually 
found  in  intimate  association  with,  and  beneath  the  peritoneal 
covering  of,  the  caecum — the  same  layer  of  serous  membrane  being 
reflected  over  both  (Fig.  8).  Or  the  appendix  may  be  partially 
or  wholly  intra-peritoneal,  and  yet  escape  detection  because  of  its 
situation  in  the  ileo-caecal  fossa,  or  in  some  other  pocket  of  peritoneum 
around  the  caput  coli.  Again  the  appendix  may  have  slipped  into 
a  hernial  sac,  and  thus  elude  the  surgeon.  In  all  such  cases  the 
operator  should  first  locate  the  caecum,  and  then  follow  down  one 
of  its  longitudinal  bands,  when  these  can  be  recognized,  until  the 
base  of  the  appendix  appears;  it  will  then  usually  be  possible  to 
perceive  the  situation  of  the  rest  of  the  organ.  Exceptionally  neither 
the  appendix  nor  caecum  can  be  found  in  the  right  iliac  fossa;  here 


298  Appendicitis 

it  is  probable  that  the  caecum  retains  its  foetal  position  high  in  the 
abdominal  cavity,  or  even  in  the  right  or  left  hypochondriac  region. 

Various  circumstances  due  to  the  inflammatory  changes  them- 
selves often  combine  to  conceal  the  appendix.  Chief  among  these 
is  the  presence  of  adhesions,  which,  in  long  standing  cases,  may 
acquire  such  bulk  and  vascularity  that  the  unwary  operator  may 
congratulate  himself  on  having  discovered  the  appendix  when  in 
reality  he  is  dealing  with  neighboring  bands  of  adhesions.  If,  in 
addition  to  the  presence  of  bands  of  adhesions  and  perhaps  pus,  the 
appendix  be  subserous,  the  determination  of  the  whereabouts  of  the 
organ  is  sometimes  exceedingly  difficult,  and  its  removal  is  particu- 
larly arduous.  Should  such  conditions  exist  it  may  be  advisable  to 
cut  through  the  external  layer  of  the  ascending  meso-colon  in  order 
to  gain  free  access  to  the  appendix.  This  procedure  reduces  to  a 
minimum  the  danger  of  infection  of  the  general  peritoneal  cavity. 

The  appendix  is  sometimes  embedded  in  a  great  mass  of  fibrin- 
ous exudate.  If  this  cannot  be  readily  removed,  its  thickest  and 
firmest  portion,  which  usually  corresponds  to  the  seat  of  primary 
disease  of  the  appendix,  should  be  incised,  whereupon  the  appen- 
dix will  be  readily  detected.  Again  the  appendix  may  be  so  rolled 
up  in  a  fold  of  omentum  that  it  is  impossible  to  define  its  outline. 
In  these  cases  it  is  proper  to  ligate  and  cut  away  the  omentum  along 
its  attachment  to  the  appendix,  after  which  the  appendix  itself  can 
usually  be  freed  with  facility.  This  method  ensures  control  of  haem- 
orrhage from  the  omentum  and  permits  of  ready  manipulation  of 
the  appendix. 

Sometimes,  either  because  it  is  subserous,  or  because  of  ad- 
hesions, it  is  impossible  to  bring  the  tip  of  the  appendix  into  the 
operative  field.  Under  these  circumstances  it  is  sometimes  possible, 
after  ligating  and  dividing  the  base  of  the  appendix,  to  strip  it  out  of 
its  peritoneal  coat  as  a  finger  is  pulled  out  of  a  glove;  by  thus  remov- 
ing all  but  the  serous  covering  the  entire  area  of  infection  is  taken 
away,  and  the  serous  envelope  cannot  cause  a  recurrence  of  the 
disease.  It  is  often  much  easier  to  ligate  and  divide  the  base  of  the 
appendix  first,  and  subsequently  to  ligate  its  mesentery  and  detach 
the  remainder  of  the  organ ;  especially  convenient  is  this  procedure 
where  the  wound  is  deep  and  where  the  appendix  runs  in  a  northerly 
,  direction  posterior  to  the  caecum.     When  once  the  base  of  the  organ 


Treatment  •  299 

is  divided,  and  the  first  section  of  the  mesentery  ligated  and  cut,  it 
will  be  found  that  the  direction  and  location  of  the  remainder  of  the 
organ  can  be  very  much  more  readily  detected,  and  its  removal 
accomplished  without  difficulty. 

A  very  fat  meso-appendix,  unless  properly  treated,  often  com- 
plicates the  removal  of  the  appendix,  especially  by  giving  rise  to 
troublesome  haemorrhage.  A  fat  meso-appendix  is  always  friable 
and  it  is  likely  to  be  torn  during  the  operative  manipulations  attend- 
ing the  removal  of  the  appendix,  especially  when  the  application  of 
the  ligatures  is  undertaken.  It  is  best  to  ligate  a  fat  meso-appendix 
in  sections,  and  to  cut  away  each  portion  as  the  ligatures  are  tight- 
ened. This  procedure  minimizes  the  danger  of  laceration  and  con- 
sequent haemorrhage. 

At  times  there  is  necrosis  or  gangrene  of  the  apex  of  the  cacum. 
If  such  be  the  case,  it  will  often  be  found  that  it  is  impossible  to 
secure  any  tissue  sufficiently  healthy  to  retain  sutures  introduced 
for  the  purpose  of  closing  the  opening.  An  attempt,  however, 
should  be  made  to  close  it  by  the  introduction  into  the  csecum, 
wide  of  the  necrotic  area,  of  sutures  so  placed  as  to  include  as  healthy 
tissue  as  is  possible.  Too  much  tension  on  the  sutures  must  be 
avoided;  and  it  will  often  be  found  that  mattress  sutures  hold  better 
than  the  ordinary  Lembert  stitches.  When  the  perforated  or  gan- 
grenous area  approaches  too  closely  the  ileo-caecal  valve,  great  care 
must  be  exercised  to  avoid  encroaching  too  much  upon  this  orifice; 
ordinarily,  hovi^ever,  no  fear  of  producing  stenosis  need  be  enter- 
tained. Whether  the  opening  is  sufficiently  patulous  can  be 
determined  by  invaginating  the  ileum  upon  the  tip  of  the 
finger  through  the  ileo-caecal  valve.  If  any  doubt  exists  as  to 
its  sufficiency  an  ileo-colostomy  should  be  made  at  once. 
When  the  caecum  cannot  be  closed  securely,  the  great  omen- 
tum may  be  carried  down  to  the  area  affected,  and  a  portion  of  it 
made  to  serve  as  a  flap,  by  stitching  it  in  place  so  as  to  reinforce 
the  sutured  area;  or  if  a  large  meso-appendix  be  present  it  may  be 
utilized  for  the  same  purpose.  I  have  frequently  done  this  with 
good  results.  I  have  also  employed  Cargile  membrane  on  numer- 
ous occasions,  but  much  prefer  an  omental  flap.  In  certain  cases 
it  will  be  found  impossible  to  close  the  gangrenous  area.  All  that 
can  be  done  under  such  circumstances  is  to  wall  off  the  general  peri- 
toneal cavity  by  a  coffer-dam  of  gauze  and  to  leave  the  gangrenous 


300  Appendicitis 

area  in  situ,  but  exposed  beneath  the  wound.  In  a  few  days  the 
slough  will  be  cast,  with  the  formation  of  a  faecal  fistula,  which  may 
be  closed  at  a  subsequent  operation,  if  repair  does  not  take  place 
spontaneously.  In  many  of  these  cases  the  surgeon's  ingenuity  is 
taxed  to  the  utmost,  and  the  greater  his  experience  the  more  likely 
are  his  endeavors  to  be  attended  by  a  successful  outcome.  It  is 
well  to  bear  in  mind  that  if  the  gangrenous  area  be  invaginated,  and 
the  abdominal  wound  be  immediately  closed,  the  development  of  a 
fatal  peritonitis  is  a  most  likely  event. 

In  a  considerable  number  of  cases  the  appendix  is  found  adherent 
to  one  or  another  of  the  abdominal  or  pelvic  organs.  In  these  cases 
great  care  must  be  exercised  in  the  removal  of  the  appendix  because 
of  the  liability  of  the  occurrence  of  haemorrhage,  or  the  subsequent 
development  of  a  faecal  fistula.  Haemorrhage  is  especially  to  be 
feared  in  those  cases,  fortunately  rare,  in  which  the  appendix  is 
discovered  adherent  to  the  iliac  vessels.  After  detachment  of  the 
appendix  the  vessel  itself  must  be  carefully  investigated,  as  in  some 
cases  it  has  been  found  to  be  the  seat  of  necrosis  or  more  or  less 
gangrene.  If  such  be  the  condition,  and  the  weak  point  in  the  wall 
of  the  vein  is  not  reinforced  by  peritoneal  flaps,  fatal  secondary 
haemorrhage  may  ensue.  Where  the  appendix  is  adherent  to  the  small 
intestine,  the  colon,  or  the  sigmoid  flexure,  it  is  usually  advisable 
to  invert  the  point  of  its  attachment,  to  these  structures  with  a  few 
Lembert  sutures:  these  serve  to  control  any  haemorrhage  from  the 
point  of  contact,  and  lessen  the  likehhood  of  subsequent  perforation. 

SEQUELS  OF  THE  OPERATION. 

Unfavorable  sequels  of  an  operation  for  appendicitis  are  almost 
unknown  when  the  operation  has  been  performed  within  the  first 
twenty-four  or  thirty-six  hours  of  the  disease.  Almost  every  one 
of  the  serious  and  at  times  life  threatening  complications  that 
follow  an  operation  may  be  directly  laid  to  procrastination  in 
seeking  the  surgeon's  knife. 

In  suppurative  cases  which  have  been  operated  upon  with  ap- 
parent success  there  may  appear  in  a  week  or  more  after  the  opera- 
tion one  or  more  secondary  or  residual  abscesses.  In  cases  which 
have  been  subject  to  more  or  less  widespreading  peritonitis  for 
several  days  before  operation,  one  or  more  small  independent  col- 


Treatment  301 

lections  of  pus  may  be  present  at  the  time  of  operation  and  be  over- 
looked unless  the  surgeon  takes  care  to  note  the  conditions  present 
in  areas  adjacent  to  the  immediate  vicinity  of  the  appendix  where 
the  major  abscess  is  usually  found.  Particularly  is  this  true  of  the 
pelvis.  I  have  not  infrequently  found  only  a  small  amount  of  en- 
capsulated pus  about  the  appendix  when  the  pelvis  contained  a 
large  collection  of  pus.  Less  commonly  smaller  abscesses  may 
be  present  beneath  the  mesentery  at  a  distance,  or  enveloped  in  the 
omentum  or  loops  of  bowel.  A  subdiaphragmatic  abscess  also  may 
co-exist.  Apparent  recovery  from  the  operation  may  be  followed  by 
increase  of  symptoms  due  to  enlargement  of  the  overlooked  abscesses. 
For  this  reason,  unless  I  feel  sure  from  the  physical  examination 
that  a  peri-appendicular  abscess  is  single  I  do  not  perform  the  simple 
extra-peritoneal  evacuation  of  the  abscess  but  rather  open  into  the 
free  peritoneal  cavity  and  explore  the  suspicious  areas  immediately 
adjacent,  particularly  the  pelvis. 

In  other  instances  the  collections  of  pus  noted  subsequent  to 
operation  are  purely  a  secondary  development  which  must  be 
charged  to  defects  of  drainage.  The  difficulties  of  ideal  drain- 
age of  the  peritoneal  cavity  are  too  evident  for  anything  more  than 
comment.  Fortunately  it  is  usually  possible  to  attain  our  object 
satisfactorily  from  the  standpoint  of  results.  In  a  series  of  2400 
cases  forty-seven  instances  of  secondary  abscess  were  encountered. 
Of  these  thirty-four  recovered  and  thirteen  died. 

Suspicion  is  aroused  of  the  presence  of  a  secondary  abscess  when 
the  patient  still  shows  the  signs  of  infection  and  toxic  absorption 
after  the  site  of  the  primary  operation  is  clean  and  healthy  in 
appearance.  The  encapsulated  focus  is  at  times  palpable  through 
the  abdominal  wall  or  if  in  the  pelvis  it  can  be  felt  by  rectum  or 
vagina.  Tenderness  is  usually  present.  Rigidity  and  spasm  are 
less  constant.  Distention,  which  is  not  uncommon,  masks  the  pal- 
patory findings.  When  the  collection  is  immediately  beneath  the 
diaphragm  the  signs  and  symptoms  are  those  elsewhere  detailed  in 
connection  with  subdiaphragmatic  abscess.  Incision  and  drainage 
at  the  earliest  moment  is  the  only  treatment  that  offers  hope  of 
recovery. 

I  have  recently  had  under  my  care  at  the  German  Hospital  a  case 
of  suppurative  appendicitis  where  the  appendix  was  removed  and 
drainage  instituted  by  the  transperitoneal  route.     The  wound  granu- 


302  Appendicitis 

lated  satisfactorily,  and  the  patient  was  discharged  from  the  hospi- 
tal, and  returned  to  the  dispensary  to  have  the  wound  dressed. 
About  two  weeks  subsequently  a  residual  abscess  formed,  for 
which  the  patient  was  again  admitted  to  the  hospital.  A  large 
fluctuating  abscess  was  pointing  above  the  iliac  spine.  I  opened 
this  by  direct  incision,  and  evacuated  a  large  quantity  of  offensive 
pus.  For  a  couple  of  days  the  boy  did  well;  but  he  then  began  to 
vomit,  his  fever  became  higher,  his  bowels  were  obstinately  con- 
stipated, and  it  was  evident  that  there  was  secondary  peritoneal  in- 
volvement. Recognizing  that  longer  delay  meant  death,  I  opened 
his  belly  in  the  hypogastric  region,  turned  out  his  intestines,  which 
I  found  adherent  in  innumerable  places,  and  separated  all  the  ad- 
hesions. There  were,  I  think,  at  least  seven  different  abscesses 
among  the  intestinal  coils,  one  abscess  being  beneath  the  trans- 
verse meso-colon  in  the  epigastric  region.  Drainage  was  instituted 
by  means  of  a  glass  tube  to  the  pelvis  and  multiple  wicks  of  gauze 
throughout  the  abdomen,  and  the  wound  of  operation  was  partly 
closed.  The  lad's  fever  subsided,  his  stomach  became  retentive, 
and  although  multiple  faecal  fistulas  developed,  he  is  now,  I  am 
happy  to  say,  well. 

At  times  in  cases  of  suppurative  appendicitis  there  may  be  found 
an  abscess  in  the  omentum,  apparently  entirely  unconnected 
with  the  original  focus  of  infection.  Such  an  abscess  is  as  a  rule  best 
treated  by  excision  of  the  entire  area  of  omentum  involved  in  the 
process.  If  adhesions  render  this  course  impracticable,  care  should 
be  taken  to  secure  adequate  drainage  from  the  abscess  cavity  after 
evacuating  its  contents. 

In  certain  of  the  suppurative  and  gangrenous  cases  of  appen- 
dicitis, and  particularly  when  the  abscess  or  the  appendix  lies 
behind  or  to  the  outer  side  of  the  caecum  or  colon,  the  surrounding 
tissues  will  be  found  semigangrenous.  In  this  type  of  the  disease 
the  wound  must  be  treated  as  an  open  one,  no  attempt  being  made 
to  close  it.  I  have  seen  partial  or  nearly  complete  closure  followed 
by  an  extension  of  the  inflammation  to  the  neighboring  bowels, 
resulting  in  paresis  and  distention,  which,  to  the  inexperienced, 
may  simulate  intestinal  obstruction,  and  especially  so  if  the  patient 
is  subject  to  paroxysmal  pain  due  to  gas. 

When  these  wounds  appear  thoroughly  healthy  (filled  with 
granulations)  it  is  the  practice  of  some  to  introduce  sutures  in  the 


Treatment  303 

hope  that  the  subsequent  tendency  to  hernia  will  be  less.  I  regard 
this  as  a  perfectly  useless  procedure;  not  only  does  it  do  no  good, 
but  it  may  result  in  harm  by  confining  septic  material  in  the  wound. 
To  satisfy  oneself  that  this  procedure  is  useless  it  is  simply  necessary 
to  repair  a  few  hernias  following  such  cases.  Immediately  after 
division  of  the  abdominal  wall,  in  any  case,  there  is  retraction  of  the 
different  layers,  particularly  of  the  aponeurosis  of  the  external 
oblique  muscle  on  the  outer  side  of  the  wound,  where  it  is  least  re- 
stricted in  its  movements;  and  nothing  short  of  apposing  layer  to 
layer  and  maintaining  the  apposition  will  surely  guard  against  hernia. 
It  can  readily  be  seen  that  this  is  not  done  even  when  through  and 
through  sutures  alone  are  used  for  primary  repair  of  the  wound;  and 
hence  it  is  even  less  useful  in  sewing  up  a  granulating  wound. 

Acute  intestinal  obstruction  is  a  sequel  which  is  really  more 
due  to  the  appendicitis  itself  than  to  the  operation,  but  is  more  con- 
veniently considered  in  this  place.  In  my  experience  this  serious 
complication  occurred  in  t,^  of  2400  cases,  or  1.37  %.  It  may 
develop  before  any  operation  is  performed,  or  its  onset  may  be  de- 
layed for  weeks,  months,  and  in  rare  instances  for  years,  after  the 
acute  affection.  Its  occurrence  in  connection  with  chronic  ap- 
pendicitis has  already  been  discussed. 

It  is,  of  course,  most  likely  to  occur  where  generalized  ad- 
hesions are  present,  and  especially  when  the  small  bowel  is  in- 
volved. The  caecum,  the  colon,  and  the  sigmoid  flexure  are  rela- 
tively so  immovable  that  obstruction  of  these  parts  of  the  intestinal 
tract  is  comparatively  rare.  It  also  seems  that  the  presence  of  a 
faecal  fistula,  in  cases  where  many  adhesions  were  present  at  opera- 
tion, renders  the  subsequent  development  of  intestinal  obstruction 
less  liable  to  occur.  Perhaps  this  is  so  because  the  drainage  of  the 
intestinal  tract  present  in  such  cases  keeps  the  small  bowel  fairly 
quiet,  and  by  thus  lessening  peristalsis  enables  the  inflamed 
bowels  to  recover  with  as  few  kinks  and  adhesions  as  possible. 
On  the  other  hand  the  existence  of  obstruction  below  the  seat  of  a 
faecal  fistula  necessarily  keeps  this  from  healing. 

Post-operative  obstruction  may  be  one  of  three  kinds: 

1.  Those  following  immediately  after  operation. 

2.  Those  the  result  of  septic  peritonitis. 

3.  Those  the  result  of  mechanical  obstruction. 


304  Appendicitis 

1.  The  obstruction  following  immediately  after  operation  is 
in  most  cases  due  to  excessive  handling  of  viscera,  or  at  times  caused 
merely  by  prolonged  anaesthesia  and  operation.  It  is  a  true  form 
of  organic  ileus.  It  may  be  entirely  eliminated  by  the  surgeon  if 
proper  care  is  taken  not  unnecessarily  to  expose  or  handle  the 
intestines  and  sufficient  gentleness  is  used  in  handling  instruments, 
gauze  packs,  etc.,  in  the  abdominal  cavity. 

2.  Post-operative  obstruction  due  to  sepsis  and  paralysis  of  the 
bowel  musculature  is  the  commonest  of  the  three  forms  in  appen- 
dicitis. In  the  presence  of  a  widespread  and  virulent  peritonitis  at 
the  time  of  operation  it  may  be  at  times  unavoidable. 

3.  Obstruction  due  to  mechanical  causes  occurs  generally  in 
septic  cases.  It  may  be  due  to  angulation  or  constriction  by  new  ad- 
hesions or  the  simple  glueing  together  of  the  intestines  by  plastic 
exudate. 

Drainage,  particularly  gauze,  with  its  tendency  to  excite  adhe- 
sions, predisposes  to  obstruction  and  should  therefore  be  employed 
as  sparingly  as  possible. 

The  first  variety  of  obstruction  rarely  shows  itself  as  more  than 
a  transient  paralysis  of  the  bowels  manifesting  itself  by  cessation  of 
peristalsis  and  by  abdominal  distention.  Commonly,  as  the  patient 
reacts,  the  dynamic  force  of  the  bowel  is  regained  and  the  symptoms 
of  ileus  are  at  an  end  without  ever  having  excited  annoyance  or 
alarm.  Occasionally  the  distention  thus  engendered  becomes 
marked  and  distressing. 

We  may  then  try  various  measures  which  are  believed  to  exercise 
a  stimulating  effect  upon  peristalsis.  Cold  over  the  abdomen  or  hot 
stupes,  if  the  wound  permits  of  it,  may  be  tried.  The  introduction 
of  the  rectal  tube  or  an  enema  either  of  ordinary  soap  suds  or  con- 
taining a  stimulating  substance  such  as  turpentine  or  asafoetida 
will  sometimes  initiate  effective  peristalsis.  If  nausea  or  regurgi- 
tation be  present  the  stomach  tube  should  be  used  and  the  same  is 
true  if  the  distention  is  upper  abdominal  or  if  by  percussion  the 
stomach  appears  distended.  An  overdistended  viscus  has  small 
chance  to  recover  from  paralysis  until  the  distention  is  reduced. 
The  only  drug  of  service  is  eserin,  which  may  be  given  hypodermic- 
ally  in  doses  of  gr.  1-40,  repeated  every  hour  until  six  or  eight 
doses  are  given.     With  every  third  dose  it  is  m.y  practice  to  com- 


Treatment  305 

bine  gr.  1/60  of  strychnia  to  counteract  the  depression  sometimes 
caused  by  eserin.  With  hormone  treatment  of  deficient  peristalsis 
I  have  had  no  experience,  and  as  at  present  recommended,  but  Httle 
can  be  said  of  it. 

The  second  variety  of  obstruction,  which  is  due  to  sepsis  and 
toxic  paralysis  of  the  bowel  musculature,  can  be  combated  only  by 
the  general  measures  applicable  to  intraperitoneal  infections  as 
before  outlined.  The  methods  given  above  may  aid  also  in  a 
degree.  Only  in  the  event  that  a  definite  purulent  collection  has 
formed  will  re-operation  be  necessary,  or  advisable. 

While  it  is  true  that  the  first  two  varieties  of  obstruction  do  not 
require  operation,  great  care  must  be  taken  to  avoid  regarding  a  case 
of  true  mechanical  ileus  as  belonging  to  one  of  the  two  former  classes, 
since  in  no  other  condition  is  timely  operation  so  imperative.  The 
cure  of  angulations,  twists  or  constrictions  when  they  have  pro- 
duced obstruction  can  be  accomplished  only  by  operation,  and  time 
employed  in  lesser  measures  only  lessens  the  chances  of  recovery. 
There  may  be  some  difficulty  in  recognizing  the  condition.  The 
diagnosis  must  be  made  usually  by  the  occurrence  of  characteristic 
intermittent  colicky  pain,  accompanied  by  hyper-peristalsis  and 
borborygmi  with  increasing  distention  and  inability  to  pass  flatus 
and  to  move  the  bowels.  Nausea  and  vomiting  may  occur,  but 
are  frequently  not  prominent  until  later.  If  the  vomitus  becomes 
faecal  the  prognosis  is  bad.  Similarly  peristalsis,  which  is  at  first 
violent  and  strong,  later  diminishes  and  finally  ceases  when  disten- 
tion becomes  marked. 

The  pulse  and  temperature  are  at  first  but  little  disturbed,  but 
both  rise  in  the  advanced  stages.  Leucocytosis  is  an  early  and  pro- 
nounced feature.  Every  effort  should  be  made  to  arrive  at  a 
correct  conclusion  before  the  later  symptoms  appear  since  prompt 
operation  immeasurably  improves  the  chances  of  recovery. 

One  of  the  most  important  sequels  of  appendicitis,  whether  asso- 
ciated with  suppuration  or  not,  is  faecal  fistula.  This  is  of  com- 
parative frequency  after  operations,  and  there  is  no  question  that 
the  likelihood  of  its  occurrence  is  much  increased  by  delay  in  the 
performance  of  the  operation. 

Appendicular  fistulas  occur  as  one  of  two  varieties — the  internal 
and  the  external.     In  the  internal  variety  the  channel  of  communi- 


3o6  Appendicitis 

cation,  or  the  fistula,  is  in  direct  communication  with  some  hollow 
abdominal  viscus,  and  is  entirely  within  the  abdominal  cavity.  Any 
of  the  viscera  in  close  proximity  to  the  appendix  may  be  involved— 
the  intestinal  tract,  the  bladder,  a  dilated  portion  of  the  dilated 
ureter,  etc.  In  the  external  variety  the  fistula  is  in  communication 
with  the  exterior  through  the  abdominal  wall.  There  m.ay  be  only 
a  single  sinus,  or  there  may  be  a  number  of  fistulous  tracts  with  a 
common  or  two  or  more  external  openings.  The  extent  of  the  lesions 
and  the  organ  or  organs  implicated  cannot  as  a  rule  be  determined 
until  the  viscera  have  been  exposed  by  operation. 

Of  the  external  fistulas  there  are  two  varieties — the  simple 
and  the  faecal.  Simple  fistula  may  also  be  divided  into:  (i)  Those 
that  are  the  result  of  an  unhealed  abscess  cavity,  and  follow  the  use 
of  drainage.  They  are  merely  suppurating  tracts  that  discharge  pus, 
and  have  a  tendency  to  heal  spontaneously.  Frequently  an  in- 
fected suture  or  ligature  at  the  bottom  of  such  a  tract,  or  a  faecal 
calculus  (rarely  a  piece  of  gauze)  is  the  cause  of  the  delayed  healing. 
They  are  more  properly  sinuses.  (2)  Those  in  which  the  fistula  is 
in  communication  wdth  the  lumen  of  an  appendix  and  from  which 
there  has  never  been  discharged  anything  but  mucus.  This  type 
of  fistula  is  encountered  in  cases  in  which  the  lumen  of  the  appendix 
has  become  entirely  occluded  or  obliterated  at  some  point,  or  in 
which  there  has  occurred  spontaneous  separation  of  the  appendix  in 
its  continuity.  This  form  of  fistula  is  quite  rare  and  is  only  ob- 
served when  some  portion  of  the  mucous  membrane  of  the  appendix 
is  left  in  situ.  In  one  case  which  I  observed  there  was  a  small  ex- 
ternal opening,  not  large  enough  to  permit  the  passage  of  a  small 
probe,  which  intermittently  discharged  mucus  only.  At  the  time 
of  the  original  operation  it  had  been  noted  that  the  appendix  had 
been  separated  from  the  caecum.  Shortly  after  the  operation  there 
developed  this  fistula,  w'hich  was  treated  expectantly,  in  the  hope 
that  it  would  heal  spontaneously.  This,  however,  did  not  occur. 
At  the  secondary  operation  the  remnant  of  the  appendix  was  found 
directly  attached  to  the  abdominal  wall  and  draining  itself  through 
the  fistula.  A  prompt  recovery  followed  its  removal.  A  somewhat 
similar  case,  recorded  by  Jopson,  is  referred  to  at  page  loi. 

FcBcal  fistula  following  appendicitis  occurs  in  the  two  following 
varieties:  (i)  Those  cases  in  which  the  fistula  discharges  through 


Treatment  307 

the  lumen  of  a  perforated  appendix  and  from  which  as  a  rule  at 
first  faecal  matter,  and  later  chiefly  mucus  is  discharged.  (2)  Those 
in  which  the  fistula  is  either  caused  by  pressure  necrosis  upon,  or 
necrotic  inflammation  of  the  caecum,  the  ascending  colon,  the  small 
intestine,  or  both  the  small  and  large  intestines.  In  this  variety 
the  fistula  may  be  so  extensive  as  practically  to  constitute  an  artificial 
anus. 

The  exciting  causes  of  faecal  fistulas  are  those  which  are  active 
in  the  production  of  appendicitis,  the  destructive  activity  of  patho- 
genic micro-organisms.  As  a  result  of  inflammation  in  and  about 
the  appendix,  necrosis  and  softening  of  adjacent  or  contiguous  bowel 
may  occur  and  the  wall  of  such  bowel  breaks  down,  particularly 
if  pus  be  present.  While  there  are  some  cases  in  which  pressure 
necrosis  produced  by  inflammatory  lymph  results  in  the  formation 
of  a  faecal  fistula,  although  pus  either  is  not  found  or  is  present  in 
such  small  quantity  as  to  be  scarcely  discernible,  yet  abscess  forma- 
tion is  undoubtedly  the  precipitating  cause  of  faecal  fistula  in  the 
great  majority  of  cases.  In  many  cases  there  will  be  found  a  large 
perforation  into  the  bowel,  or  it  will  be  found  that  the  appendix 
has  separated  in  its  continuity,  and  that  the  contents  of  the  bowel 
are  escaping  from  its  proximal  end.  If  at  operation  it  be  found 
necessary  to  insert  stitches  into  an  inflamed  bowel,  especial  care 
must  be  exercised  not  to  introduce  them  too  closely  nor  to  tie  them 
too  tight,  as  inattention  to  either  of  these  points  may  result  in  the 
formation  of  a  faecal  fistula. 

In  many  cases  of  faecal  fistula  persistence  in  the  use  of  a  drainage 
tube  is  one  of  the  most  active  factors  in  preventing  spontaneous 
healing.  I  have  seen  a  number  of  cases  in  which  removal  of  a 
drainage  tube  that  had  been  worn  for  weeks  was  speedily  followed 
by  spontaneous  healing  of  the  fistulous  tract.  In  particular  I 
recall  the  case  of  a  young  man,  whom  I  saw  in  consultation  and  who 
had  recently  been  operated  on  twice  for  appendicitis,  and  then 
presented  two  fistulas.  One  on  the  right  side  discharged  bile  and 
faeces,  and  another,  on  the  left  side,  discharged  pus.  In  the  fistulous 
tract  on  the  right  side  there  was,  and  had  been  for  some  weeks,  a 
large-sized  rubber  drainage  tube,  which  extended  to  the  bottom 
of  the  pelvis.  Removal  of  the  drainage  tube  was  followed  by  spon- 
taneous healing  of  the  fistula  within  a  short  time. 


3o8  Appendicitis 

It  is  not  at  all  unusual  for  an  appendicular  fistula  to  make  its 
appearance  a  week  or  ten  days  after  an  operation  for  acute  appen- 
dicitis, and  one  should  not  dismiss  from  the  mind  the  possibility  of 
such  a  sequel  occurring  until  the  abscess  cavity  has  been  in  great 
part  obliterated,  or  even  until  the  wound  has  healed. 

The  following  is  an  interesting  case  in  which  I  operated  for  the 
cure  of  fistula,  the  result  of  an  attack  of  appendicitis  which  was  not 
recognized  until  an  abscess  had  formed: 

The  patient  was  a  young  woman.  The  operation  was  not  a  complete 
one,  in  that  the  appendix  was  not  removed  at  the  time  of  the  evacuation  of 
the  abscess.  On  account  of  the  softened  condition  of  the  intestine  forming 
the  wall  of  the  abscess  cavity,  and  because  the  appendix  was  not  readily 
accessible,  it  was  deemed  advisable  not  to  attempt  its  removal,  but  to  leave 
it  for  excision  at  a  subsequent  operation.  The  abscess  cavity  was  treated 
by  packing.  Ten  days  after  the  operation  the  dressings  were  found  to  be 
soiled,  chiefly  with  bile.  The  fistula  not  only  refused  to  heal  spontaneously, 
but  in  addition  there  developed  a  most  painful  eczema  of  the  skin  surround- 
ing the  external  orifice  of  the  fistula.  All  the  well-known  topical  applica- 
tions proved  of  no  avail.  Operation  became  imperative,  but  the  patient's 
condition  was  exceedingly  bad.  Because  of  the  painfully  irritated  condition 
of  the  skin,  all  nourishment  by  the  mouth  had  to  be  suspended,  and  nutri- 
tious enemata  alone  were  given.  The  latter  provoked  irritation  of  the 
rectum.  The  operation  was  attended  by  considerable  difficulty.  There  were 
widespread  adhesions  that  bound  the  caecum  to  the  small  intestines  and  to 
the  region  of  the  gall-bladder,  and  these  necessitated  extensive  dissection. 
The  fistula  was  found  to  involve  the  jejunum  high  up,  and  called  for  resection. 
The  former  abscess  cavity  was  still  present;  its  interior  was  lined  with  a 
grayish,  unhealthy  looking,  granulating  surface,  which  was  stimulated,  and 
the  cavity  was  again  packed  with  iodoform  gauze.  The  abdominal  wound 
was  closed,  except  for  a  short  distance,  an  opening  being  left  to  permit  of 
subsequent  removal  of  the  gauze.  Two  weeks  after  the  operation  the  patient 
complained  of  pain.  On  removal  of  the  dressings  it  was  found  that  the  fistula 
had  recurred;  in  fact,  that  it  was  worse  than  it  had  been  before  the  operation. 
The  matter  discharged  from  the  fistula  was  fluid;  and  if  milk,  for  instance, 
were  swallowed,  it  was  discharged  from  the  wound  a  few  moments  after  it 
was  received  into  the  stomach.  Bile  also  escaped  through  the  fistula.  Owing 
to  the  nature  of  the  fistula  and  the  return  of  the  eczema,  another  operation 
was  determined  upon.  The  opening  in  the  small  intestine  was  found  some 
distance  removed  from  the  previous  lesion,  and  the  line  of  suture  of  the  former 
operation  was  still  intact.  There  was  found  in  the  jejunum  a  large  opening, 
through  which  the  contents  of  the  bowel  escaped.  The  entire  duodenum 
was  ballooned  and  very  much  attenuated.  The  jejunum  was  excised  to  the 
extent  of  five  inches.     The  bowel  was  closed  by  end-to-end  anastomosis,  and 


Treatment  309 

the  thinned  portion  was  reinforced  by  peritoneal  flaps.  The  abscess  cavity  was 
again  packed  with  gauze,  and  the  abdominal  wound  was  closed  except  at  the 
lower  angle,  which  was  left  open  to  afford  drainage.  This  operation  was  a 
success.  The  former  abscess  cavity  soon  granulated  to  the  surface,  and 
cicatrization  was  complete  in  a  short  time. 

In  the  external  variety  of  appendiceal  fistula  the  character 
of  the  discharge  varies  greatly.  Although  profuse  at  first,  the 
faecal  character  of  the  discharge  usually  ceases  in  a  short  time, 
and  the  discharge  becomes  mucous  or  muco-purulent,  and  may 
continue  indefinitely  of  such  character. 

It  has  been  my  experience  that  if  the  appendix  be  not  removed 
at  the  time  of  the  evacuation  of  the  abscess,  in  the  majority  of  cases 
it  will  be  found  to  be  the  source  of  the  fistula. 

In  a  case  already  referred  to  (p.  242),  the  patient  was  supposed 
to  be  suffering  from  a  perinephric  abscess,  which  was  evacuated 
and  drained.  Three  or  four  weeks  after  the  wound  had  healed 
the  patient  began  to  complain  of  pain  in  the  region  of  the  loin, 
and  also  of  pain  in  the  region  of  the  appendix.  He  was  then 
admitted  to  the  German  Hospital.  While  being  placed  upon  the 
operating  table,  under  the  influence  of  the  anaesthetic,  there  was 
detected  a  distinctly  faecal  odor,  as  though  the  patient  had  had 
an  evacuation  of  his  bowels.  On  examining  the  site  of  the  former 
operation  there  was  found  a  free  discharge  of  faecal  matter  through 
an  opening  in  the  cicatrix.  This  region  was  carefully  protected, 
and  the  patient  placed  in  the  dorsal  position  and  an  incision  made 
over  the  region  of  the  appendix,  which,  when  exposed,  was  found 
to  be  post-caecal  and  post-colic  and  to  be  in  communication  with 
the  faecal  fistula  in  the  loin.  The  appendix  was  much  dilated, 
and  permitted  of  the  passage  through  it  to  the  fistula  of  the  contents 
of  the  caecum.  The  appendix  was  removed,  the  abdominal  wound 
closed,  and  drainage  introduced  into  the  former  fistulous  tract. 
Complete  recovery  ensued. 

The  internal  variety  of  fistula,  the  result  of  the  evacuation 
of  an  appendicular  abscess  into  a  hollow  viscus,  is  believed  by 
some  to  be  a  fortunate  termination  of  such  a  case.  It  has  been 
my  lot  to  see  many  cases  in  which  the  result  has  been  most  dis- 
astrous. In  one  case  there  was  a  fistulous  communication  with 
the  bladder,  which  eventually  cost  the  patient  his  life;  in  another 


3IO  Appendicitis 

case  the  fistulous  tract  emptied  into  the  dilated  portion  of  the 
ureter,  and  faecal  matter  was  discharged  into  the  ureter,  and  escaped 
externally  through  the  urethra;  in  another  the  fistulous  tract  com- 
municated with  the  air  passages;  and  so  on.  The  least  unfortunate 
variety  of  internal  fistula  is  that  in  which  the  communication  is 
with  the  caecum  or  ascending  colon.  I  have  operated  for  recurrent 
appendicitis  in  which,  during  the  previous  attack,  the  abscess  had 
evacuated  itself  spontaneously  through  the  colon,  resulting  in  the 
formation  of  this  variety  of  fistula. 

When  the  fistula  is  in  communication  with  another  portion 
of  the  intestinal  tract,  it  has  in  many  instances  been  the  direct 
cause  of  an  intestinal  obstruction.  The  fistulous  communication 
between  the  caecum  and  an  adjacent  loop  of  small  bowel  has  acted 
as  a  band,  beneath  which  another  loop  of  intestine  has  become 
engaged,  and  later  strangulated. 

The  constitutional  manifestations  of  faecal  fistula  are 
evidenced  by  gradual  loss  of  strength.  If  the  fistula  involves 
the  upper  portion  of  the  small  intestine,  there  occurs  rapid  loss  of 
strength  and  weight,  on  account  of  the  loss  through  the  fistula  of 
the  contents  of  the  bowel  containing  the  necessary  elements  of 
nutrition.  In  such  cases  the  patient  may  be  constantly  hungry. 
As  a  rule,  the  skin  surrounding  the  fistulous  opening  is  most  irritated 
when  the  fistula  is  high  in  the  intestinal  tract,  thus  allowing  the 
discharge  of  unaltered  bile  and  pancreatic  secretion  through  the 
wound;  whereas  if  the  fistula  is  in  the  lower  ileum,  caecum  or  colon, 
the  surrounding  skin  remains  in  fairly  good  condition. 

The  treatment  of  appendicular  fistulas  of  the  external 
variety  varies  with  the  individual  case.  It  is  always  well  to  per- 
mit nature  to  attempt  a  cure  and  such  treatment  as  is  adopted 
should  be  directed  to  maintaining  thorough  cleanliness,  and  to 
regulating  the  diet.  The  wound  should  be  dressed  as  frequently 
as  the  amount  of  discharge  requires,  usually  from  four  to  six  times 
daily.  The  surrounding  skin  should  be  protected  from  irritation 
and  for  this  purpose  I  think  nothing  is  so  satisfactory  as  oxide  of 
zinc  ointment  applied  thickly  for  a  distance  of  several  inches 
around  the  margins  of  the  wound.  It  is  the  only  ointment  I 
know  which  is  not  at  once  dissolved  and  washed  away  in  the 
discharge.     Occasionally  benefit  will  be  derived  from  painting  the 


Treatment  311 

surrounding  skin  with  collodion;  but  this  should  not  be  applied 
if  the  skin  is  already  sore,  as  it  is  then  extremely  painful  to  the 
patient. 

The  adoption  of  solid  food  in  the  patient's  diet,  avoidance  of 
laxatives  of  any  kind  by  the  mouth  and  the  daily  evacuation  of  the 
bowels  by  an  enema  are  essentials  in  the  proper  management  of  a 
fistula,  which  in  many  instances  will  heal  spontaneously  without 
further  interference.  It  is  not  wise  to  use  a  syringe  frequently 
to  irrigate  the  fistulous  tract,  such  a  course  being  as  a  rule  rather 
apt  to  delay  healing;  but  the  tract  must  be  wiped  dry  with  small 
pledgets  of  absorbent  cotton  in  the  jaws  of  dressing  forceps.  If 
the  fistula  persists  after  the  lapse  of  a  reasonable  time,  operation 
offers  the  only  hope  of  cure. 

The  operative  treatment  of  simple  fistula  should  consist  in 
exploring  the  tract  to  ascertain  if  an  infected  suture,  ligature  or 
other  foreign  body  be  the  cause.  If  this  be  so,  it  should  be  removed, 
and  the  tract  should  be  curetted  and  packed  with  gauze.  This 
usually  suffices  to  insure  a  cure;  but  I  have  known  a  simple  con- 
verted into  a  faecal  fistula  by  such  a  procedure,  so  that  it  is  well  to 
give  a  rather  cautious  prognosis. 

When  the  fistula  or  sinus  communicates  with  an  unhealed 
abscess  cavity,  the  mouth  of  the  fistula  should  be  enlarged  suffi- 
ciently to  permit  of  thorough  cleansing  and  packing.  When 
possible  without  opening  the  peritoneal  cavity,  the  mouth  of  the 
fistula  should  be  enlarged  to  a  degree  to  equal  the  transverse  diameter 
of  the  abscess  cavity  at  its  widest  part.  This  should  be  followed 
by  thorough  cleansing  and  packing. 

The  operative  treatment  of  faecal  fistula  necessitates  opening 
the  peritoneal  cavity,  removing  the  appendix  or  its  remaining 
portion,  as  the  case  may  be,  and  thoroughly  breaking  up  all  perit- 
oneal adhesions.  When  the  fistula  is  in  communication  with  one 
or  more  openings  in  the  intestine,  closure,  preferably  by  suture,  is 
to  be  attempted.  In  addition,  transplantation  of  omental  or 
peritoneal  flaps  is  to  be  advised  in  suitable  cases.  It  may  be 
necessary  to  resect  a  greater  or  less  portion  of  the  bowel,  and  to  do 
an  end-to-end  anastomosis  (circular  enterorrhaphy)  or  lateral 
implantation  or  anastomosis.  After  closing  the  fistula  in  the  best 
way  possible  under  the  circumstances,  the  sutured  area  should  be 


312  Appendicitis 

isolated  by  rubber  dam  or  gauze,  and  the  wound  treated  as  an 
open  one,  unless  the  faecal  fistula  was  very  superficial,  and  it  has 
been  possible  to  excise  all  the  infected  wall  of  the  fistula  between 
the  skin  and  its  mucous  orifice.  Of  course,  where  the  wound  must 
be  treated  by  the  open  method,  a  hernia  is  to  be  expected,  and 
this  will  require  another  operation  for  its  cure.  Occasionally  the 
opening  of  a  faecal  fistula  involving  the  caecum  is  so  situated  and 
its  margin  so  infiltrated  that  in  the  attempt  at  closure  the  securing 
of  sufficient  healthy  tissue  to  hold  the  sutures  will  transgress 
upon  the  ileo-caecal  valve.  I  have  had  occasion  to  perform  the 
operation  of  ileo-colostomy  for  the  purpose  of  relieving  the  ten- 
sion to  which  the  walls  of  the  caecum  were  necessarily  subjected 
in  the  passage  of  the  gas  and  faecal  contents  from  the  ileum  into 
the  colon.  An  uninterrupted  repair  was  thus  made  more  likely 
and  the  patient  relieved  of  danger  in  the  event  that  the  ileo-caecal 
junction  should  be  so  embarrassed  as  to  cause  obstruction  to  the 
passage  of  the  contents  of  the  small  bowel  into  the  large  bowel. 

The  abdominal  wall  may  be  infected  by  the  removal  of  a 
gangrenous  or  suppurative  appendix.  Care  should  be  taken, 
therefore,  to  let  as  little  infective  material  as  possible  come  into 
contact  with  the  abdominal  wound  either  during  the  operation  or 
while  the  wound  is  healing.  This  complication  may  be  prevented 
as  a  rule  by  the  judicious  disposition  of  gauze  or  rubber  dam. 

Usually  the  existence  of  fever,  leucocytosis,  pain  or  the  signs 
of  inflammation  in  the  wound  will  announce  the  presence  of  wound 
infection  and  every  effort  should  be  made  to  detect  this  complica- 
tion at  once  since  by  early  opening  and  drainage  the  important 
fascial  structures  may  be  prevented  from  softening  and  sloughing 
with  subsequent  hernia  formation.  Deep  abscesses,  that  is  those 
which  form  beneath  the  fascia  or  even  beneath  the  muscle  in  the 
properitoneal  tissues  may  be  very  insidious  in  their  development 
and  cause  considerable  tissue  destruction  and  even  sepsis  before 
they  are  detected.  A  precaution  which  I  do  not  know  to  have  been 
pointed  out  but  has  at  times  been  of  help  to  me  is  to  examine  the 
wound  in  every  case  of  broncho-pneumonia  developing  after  a  clean 
operation.  This  form  of  lung  infection  is  in  almost  every  instance 
embolic  in  origin  and  occasionally  the  source  of  the  hsematogenous 
infection  is  found  in  the  wound.     The  toxasmia  from  deep  infection 


Treatment  313 

of  the  abdominal  wall  may  be  very  severe  and  at  times  give  rise  to 
distention  with  lessened  or  absent  peristalsis  in  a  degree  simulating 
obstruction;  the  temperature,  however,  is  usually  high  and  the 
presence  of  pus  in  the  wound  can  usually  be  determined  by  close 
inspection  or  exploring  carefully  with  grooved  director. 

When  infection  occurs  the  wound  is  to  be  opened  freely  as  far 
as  the  infection  has  extended.  Time  is  lost  and  nothing  gained  by 
attempting  to  drain  an  undermined  wound  through  a  small  incision. 
The  incision  must  heal  from  below  by  granulation. 

Stitch  abscesses  are  occasionally  a  source  of  much  discomfort 
to  the  patient,  and  may  materially  hinder  healing  of  the  wound. 
They  must  be  laid  freely  open,  swabbed  out  with  corrosive  sublimate, 
tincture  of  iodine,  silver  nitrate,  or  other  antiseptic,  and  allowed  to 
heal  by  granulation. 

Hernia  following  operation  for  appendicitis  is  by  no  means  un- 
common. That  hernia  is  most  likely  to  develop  when  drainage  has 
been  employed  is  readily  understood,  and  the  frequency  of  hernia 
after  operation  in  cases  of  purulent  appendicitis  constitutes  one  of 
the  strongest  arguments  in  favor  of  early  operation  in  acute  cases. 
That  the  occurrence  of  hernia  in  the  absence  of  pus  is  influenced  by 
the  length  of  the  incision  will  be  generally  admitted.  In  the  very 
early  operation  and  in  the  interval  operation  I  am  frequently  able 
to  remove  the  appendix  through  an  incision  merely  large  enough  to 
allow  the  introduction  of  the  index-finger.  I  have  never  seen  a 
hernia  after  so  small  an  incision,  and  as  a  consequence  I  do  not 
advise  such  patients  to  wear  an  abdominal  support.  The  practice 
of  wearing  them  after  operation  is  a  general  one;  but  personally 
I  have  little  faith  in  the  efficacy  of  abdominal  supporters  and  I 
cannot  see  that  they  do  any  good  except  from  the  general  pres- 
sure they  afford.  Where  the  belts  have  to  be  rigged  up  with  per- 
ineal bands  it  is  my  opinion  that  the  discomfort  occasioned  far 
outweighs  the  good  they  accomplish.  So  far  as  preventing  a  hernia 
is  concerned  I  regard  them  as  absolutely  useless. 

Even  where  the  operative  wound  is  large,  if  the  case  be  a  clean 
one,  proper  suturing  of  the  abdominal  wound  should  in  the  vast 
majority  of  cases  prevent  the  subsequent  development  of  a  hernia. 
Most  important  for  this  purpose  is  the  accurate  approximation  of  the 
peritoneum  and  of  the  aponeurotic  layers  of  the  abdominal  wall — in 


314  Appendicitis 

the  incision  I  habitually  employ,  the  anterior  sheath  of  the  rectus 
muscle.  The  peritoneum  should  be  accurately  sutured  so  as  to 
bring  fairly  broad  areas  of  serous  tissue  into  contact,  and  also  leave 
no  mtra-peritoneal  protrusions  which  may  give  rise  to  adhesions. 
The  aponeurotic  layer  should  be  overlapped  by  buried  sutures,  a 
continuous  stitch  being  more  satisfactory  in  clean  cases,  since  it 
holds  the  aponeurosis  in  more  uniform  and  accurate  apposition. 
Special  attention  should  be  paid  to  the  external  portion  of  the  rectal 
sheath,  on  the  side  of  the  wound  toward  the. patient's  right,  as  this 
is  apt  to  retract  to  a  considerable  distance — much  further  than  the 
median  half  of  the  sheath.  Splint  sutures  of  silkworm  gut  including 
all  thicknesses  of  the  abdominal  wall  down  to  the  peritoneum, 
should  have  been  introduced  before  the  fascial  stitch,  but  are  not 
to  be  tied  until  after  this  is  in  place.  Superficial  sutures,  to  approxi- 
mate neatly  the  skin  between  the  splint  sutures,  will  complete  the 
closure  of  the  abdominal  wound. 

A  wound  of  even  large  size,  if  painstakingly  sutured  in  the  above 
manner,  will  be  very  unlikely  to  give  rise  to  hernia  at  a  later  date. 
In  some  cases,  however,  hernia  does  occur;  it  may  then  often  be 
justly  attributed  to  the  condition  of  the  abdominal  wall  itself,  either 
excessively  fat,  or  weak  and  flabby. 

In  the  event  of  the  development  of  hernia  from  any  cause,  be 
the  hernia  ever  so  small,  I  strongly  advise  radical  operation  for  its 
relief.  The  pernicious  influence  upon  digestion  exerted  by  hernias, 
especially  small  hernias,  is  well  known;  and  the  smaller  the  hernia, 
the  greater  the  danger  of  strangulation  passing  unnoticed,  should  it 
occur. 

The  operation  for  the  repair  of  a  ventral  hernia  occurring 
after  an  abdominal  operation  should  consist  in  the  excision  of  the 
cicatrix  and  the  careful  denudation  of  the  different  layers  of  the 
abdominal  wall  forming  the  sides  of  the  wound.  The  peritoneum 
should  always  be  opened,  any  existing  adhesions,  either  between  the 
underlying  viscera  and  the  parietal  peritoneum,  or  among  the 
viscera  themselves,  should  be  disposed  of,  and  the  hernial  sac  cut  off 
flush  with  its  neck.  The  peritoneum  and  the  different  layers  of  the 
abdominal  wall  should  then  be  sutured  in  the  manner  just  described 
for  the  closure  of  a  clean  laparotomy  wound.  The  buried  sutures 
are  preferably  of  kangaroo  tendon  or  chromicized  catgut;  and  the 


Treatment  315 

splint  sutures  are  best  made  with  silkworm  gut.  Superficial  sutures 
of  lighter  silkworm  gut  or  of  horse  hair  may  be  employed.  I  do  not 
use  a  subcuticular  stitch,  as  it  is  apt  to  leave  a  dead  space  in  the  sub- 
cutaneous tissues,  where  fluids  may  accumulate  and  delay  healing  of 
the  wound.  The  great  advantage  of  the  splint  sutures  is  that  they 
prevent  any  dead  spaces  by  embracing  the  whole  thickness  of  the 
abdominal  wall,  except  the  peritoneum;  and  that  when  they  are  tight- 
ened they  relieve,  to  a  great  extent,  the  aponeurotic  sutures  of  all 
strain.  In  very  fat  abdominal  walls  it  is  occasionally  well  to  apply  a 
buried  continuous  suture  of  catgut  in  the  subcutaneous  cellular 
tissues,  thus  ensuring  still  more  accurate  approximation  of  the  lips 
of  the  wound.  It  is  now  my  practice  in  patients  with  fat  abdominal 
walls  to  unite  the  skin  with  interrupted  catgut  or  horse -hair 
sutures,  introducing  them  one  inch  apart,  thus  providing  for 
drainage. 

ABDOMINAL  PAIN  PERSISTING  AFTER  OPERATION. 

Pain  which  persists  even  after  the  removal  of  a  diseased  appendix 
is  a  sequel  seen  sufficiently  often  to  render  a  short  discussion  of  its 
prevention  and  treatment  of  some  interest. 

If  the  operation  has  been  performed  before  the  formation  of 
many  adhesions,  that  is,  while  the  disease  is  still  confined  to  the 
appendix,  it  is  very  unusual  for  any  subsequent  discomfort  to  be 
experienced. 

At  times  the  recurrence  of  pain  brings  the  unwelcome  discovery 
that  we  have  been  mistaken  in  our  diagnosis  and  that  the  appendix 
though  diseased  was  not  the  source  of  the  patient's  discomfort. 
It  has  fallen  to  my  lot  to  remove  the  appendix  in  cases  that  subse- 
quent events  showed  to  have  been  suffering  from  movable  kidney 
or  renal  or  ureteral  calculus.  Fortunately  this  is  a  rare  occurrence 
and  is  mentioned  only  to  encourage  thoroughness  in  the  diagnosis 
of  this  usually  simple  condition.  Very  recently  two  new  conditions 
have  been  added  to  our  list  of  anomalies  in  the  region  of  the  appendix 
which  may  give  rise  to  symptoms  and  if  unrecognized  cause  distress 
after  operation.  These  are  the  so-called  Lane's  kink  and  the  caecum 
mobile.  Lane's  kink  in  its  typical  form  is  a  band  of  peritoneum 
running  from  the  posterior  parietes  to  the  inferior  surface  of  the 


3i6  Appendicitis 

ileum  near  the  ileo-csecal  valve.  It  is  not  an  uncommon  finding 
and  I  believe  but  rarely  gives  symptoms.  When,  however,  it  is 
so  well  developed  and  so  situated  that  it  can  twist,  angulate  or 
interfere  with  the  peristalsis  of  the  bowel  it  may  cause  pain  and 
particularly  constipation,  perhaps  alternating  with  diarrhoea.  When 
it  is  possible  to  do  so  the  terminal  portion  of  the  ileum  should  be 
inspected  for  the  presence  of  this  anomalous  band. 

Caecum  mobile  or  typhlatonia  appears  to  be,  according  to  Sailer, 
a  congenital  malformation  of  the  meso-colon  of  the  caecum,  of  such 
a  nature  that  for  some  distance  along  the  ascending  colon  it  maintains 
the  type  of  the  mesentery  and  is  not  attached  to  the  parietal  peri- 
toneum. This  permits  abnormal  mobility,  the  formation  of  kinks 
and  partial  or  very  rarely  complete  obstruction.  The  wall  may 
become  distended,  its  mobility  impaired  with  resulting  constipation 
and  discomfort.  Just  how  frequent  is  this  condition  cannot  now 
be  asserted  though  Wilms  and  certain  German  authors  believe  it 
to  be  excessively  common.  As  a  condition  productive  of  symptoms 
I  believe  it  to  be  very  rare,  an  opinion  which  is  based  upon  a  most 
satisfactory  experience  in  the  relief  of  symptoms  located  in  the  right 
iliac  fossa  by  the  removal  of  the  chronically  diseased  appendix. 
Still,  the  condition  should  be  borne  in  mind  and  when  in  the  course 
of  removal  of  the  appendix  it  is  seen  that  the  caecum  is  abnormally 
mobile  it  should  be  anchored  to  the  posterior  abdominal  wall  by  a 
few  retaining  sutures. 

When  adhesions  have  already  formed  about  the  appendix,  it  is 
the  rule  for  some  adhesions  to  re-form,  and  for  a  few  to  persist 
throughout  the  patient's  subsequent  life.  In  patients  who  have 
had  very  many  or  dense  adhesions  at  the  time  of  operation,  intestinal 
obstruction,  as  already  mentioned,  will  occasionally  occur.  More 
often  there  is  merely  aggravated  constipation,  or  rather  obstipation, 
with  flatulency,  consequent  either  upon  some  non-strangulating 
adhesions,  or,  as  Macewen  has  suggested,  upon  the  interference 
with  digestion  occasioned  from  removal  of  the  appendicular  secre- 
tion, and  from  impairment  of  the  efficiency  of  that  of  the  caecum. 
In  any  case  which  has  been  drained  it  is  almost  certain  that  the 
omentum  or  perhaps  some  of  the  intestinal  coils  have  become  ad- 
herent to  the  under  surface  of  the  abdominal  cicatrix;  and  in  a  large 
majority  of  such  cases  an  omental  hernia  or  even  an  enterocele  will 


Treatment  317 

form  in  the  wound.  The  dangers  of  this  last  condition,  and  the 
possibility  of  the  strangulation  of  a  small  hernia  being  overlooked, 
have  already  been  alluded  to.  Where  adhesions  to  the  abdominal 
cicatrix  exist,  the  patient  may  complain  of  tendency  to  pressure,  of 
a  more  or  less  constant  drawing  sensation,  preventing  over-exten- 
sion of  the  spine,  and  occasioning  severe  pain  on  any  sudden  move- 
ment. Some  patients  have  unexpectedly  found  themselves  relieved 
of  all  symptoms  after  some  unusually  vigorous  motion,  being  con- 
scious that  their  adhesions  have  become  separated  from  the  ab- 
dominal wall  with  a  momentary  stab  of  pain  of  unusual  severity 

A  great  many  of  these  patients  return  to  the  surgeon  seeking 
relief  from  their  pain  by  further  operative  interference.  I  have 
operated  a  number  of  times  for  such  conditions,  and  while  adhesions 
have  existed  in  the  majority  of  instances,  yet  in  some  patients  no 
cause  for  the  abdominal  discomfort  could  be  detected.  I  think  it 
therefore  not  impossible  that  a  neurotic  tendency  may  be  held 
accountable  for  this  post-operative  pain  in  certain  cases;  it  is  at  any 
rate  worth  the  while  of  both  patient  and  physician  to  first  consider 
such  remedial  measures,  other  than  operation,  as  are  available.  I 
have  frequently  prescribed  a  course  of  mild  gymnastics,  especially 
such  exercises  as  tend  to  bring  into  play  the  abdominal  muscles, 
together  with  Swedish  movements,  resistive  motions,  exercise  on 
the  parallel  bars  and  on  the  horizontal  bar.  Such  exercises  tend  to 
release  the  adhesions,  if  any  exist,  by  stretching  and  even  at  times 
rupturing  their  attachments,  but  accomplish  this  so  gradually  and 
so  gently  that  no  harm  would  be  anticipated,  and  none  has  occurred 
in  the  cases  under  my  care.  If  no  adhesions  are  present  such  a 
course  of  treatment  is  equally  proper  for  the  neurasthenia.  Abdom- 
inal massage  may  also  be  beneficial.  If  operation  is  undertaken,  the 
chances  of  new  adhesions  forming  in  even  greater  strength  and 
numbers  are  not  very  remote. 

If  a  hernia  is  suspected,  however,  I  urge  operation,  believing 
that  by  its  radical  cure  the  discomfort  of  the  patient  will  probably 
be  less,  as  his  danger  of  developing  intestinal  strangulation  certainly 
will  be. 

Pain  in  the  cicatrix  or  in  the  neighboring  abdominal  wall  may 
be  attributed  to  the  division  of  the  cutaneous  nerves  at  the  time  of 
operation.     This  is  a  sequel  which  it  is  often  more  easy  to  prevent 


3i8  Appendicitis 

than  to  remedy;  hence,  when  possible,  long  incisions  through  the 
rectus  muscle  should  be  avoided,  since,  as  was  mentioned  in  a 
previous  chapter,  some  of  the  nerves  of  the  abdominal  wall  are  liable 
to  be  divided  under  such  circumstances.  If  a  hernia  has  formed  in 
the  wound,  its  repair,  accompanied  by  dissection  and  removal  of 
the  old  scar  may  result  in  relief  of  these  symptoms.  If  any  of  the 
main  trunks  of  the  abdominal  nerves  have  been  divided,  the  rectus 
muscle  will,  as  a  consequence,  be  partially  deprived  of  its  innerva- 
tion, and  may  sag  or  bulge  slightly  in  the  area  so  affected,  favoring 
the  formation  of  ventral  hernia.  This  fact,  as  already  mentioned, 
militates  somewhat  against  the  universal  use  of  the  longitudinal 
incision  passing  through  the  outer  border  of  the  right  rectus  muscle; 
but  unless  m.ore  than  one  trunk  is  divided,  the  disability  produced 
is  negligible,  and  in  incisions  of  ordinary  length  no  main  nerve  is 
divided.  Indeed,  I  am  inclined  to  the  opinion  that  this  objection 
is  more  theoretical  than  practical,  since  I  do  not  remember  to  have 
seen  a  patient  in  whom  post-operative  functional  defects  in  the 
abdominal  wall  could  not  with  greater  justness  be  attributed  to 
some  other  condition  than  to  loss  of  innervation. 

In  separating  or  dividing  adhesions  and  dissecting  the  intestines 
free  from  each  other,  from  the  omentum,  the  pelvic  organs,  or  the 
parietal  peritoneum,  which  it  is  not  always  advisable  to  do,  all 
damage  should  be  repaired  as  soon  as  it  is  inflicted.  Areas  denuded 
of  their  serous  covering  should  be  inverted  by  Lembert  sutures  of 
fine  silk,  or  be  covered  by  a  graft  of  omentum,  stitched  in  place; 
haemorrhage  should  be  checked  by  ligature,  by  suture,  or  even  by 
packing,  this  last  method  being  only  applicable  to  bleeding  from  a 
bed  of  adhesions  where  pressure  is  possible.  Irrigations  with  hot 
solutions  will  also  aid  in  checking  the  haemorrhage. 

In  closing  the  abdominal  wound  one  of  several  methods  may 
be  employed:  (i)  Interrupted  sutures  including  all  the  layers  of 
the  abdominal  wall;  (2)  buried  sutures  uniting  the  different  layers 
of  the  abdominal  wall  individually;  and  (3)  a  combination  of  both 
methods,  or  a  modification  of  either.  The  method  of  election  de- 
pends upon  whether  or  not  drainage  is  employed,  on  the  length  and 
character  of  the  incision,  and  on  the  development  of  the  abdominal 
walls. 

In  clean  cases  where  the  wound  can  be  entirelv  closed  it  should 


Treatment  319 

always  be  united  in  layers  in  order  that  the  divided  structures  may 
be  accurately  apposed. 

In  clean  cases,  with  a  small  w^ound,  I  sometimes  use  a  single 
suture  of  chromicized  catgut  for  both  the  peritoneum  and  the 
sheath  of  the  rectus,  stitching  the  peritoneum  from  the  lower  angle 
of  the  wound  upward,  then  transfixing  the  rectus  and  its  anterior 
sheath  on  one  side  of  the  wound  without  tying  the  suture,  and 
finally  stitching  the  rectal  sheath  downward  to  the  starting  point 
at  the  lower  angle  of  the  w'ound,  where  the  two  ends  of  the  suture 
are  tied  together.  I  find  that  this  form  of  suture  not  only  obliterates 
all  dead  spaces,  but  tends  to  decrease  the  length  of  the  wound  to  a 
very  considerable  degree. 

The  peritoneum  should  first  be  closed  with  a  running  suture  of 
eight-  or  ten-day  catgut.  Often,  and  especially  in  straight  incisions 
through  the  rectus  I  include  in  this  suture  a  portion  of  the  overlying 
muscle.  Care  should  be  taken  with  this  suture  to  secure  nice 
apposition  of  the  peritoneum  in  order  to  avoid  adhesions  between 
the  viscera  and  the  resulting  scar.  Interrupted  sutures  of  silkworm 
gut  are  next  introduced  through  all  the  layers  of  the  abdominal  wall 
down  to,  but  not  including,  the  peritoneum.  These  enter  and  emerge 
at  a  distance  of  three-quarters  to  one  inch  from  the  margin  of  the 
wound  and  are  placed  at  a  distance  of  about  one  inch  from  each 
other  throughout  the  length  of  the  wound.  These  sutures  are  not 
to  be  tied  at  once  but  are  secured  at  each  end  with  a  haemostat  and 
allowed  to  hang  loose  during  the  introduction  of  the  remaining 
sutures. 

The  aponeurotic  layer  or  layers  are  next  brought  together  with 
a  running  suture  of  chromicized  catgut.  It  is  best  to  overlap  the 
fascial  margins  which  may  be  done  by  transfixing  one  side  and  then 
piercing  the  other  at  some  distance  from  its  edge.  Interrupted 
mattress  sutures  may  also  be  used  for  this  purpose  and  give  even 
better  approximation  than  the  running  sutures  though  they  are  not 
so  quickly  introduced.  The  skin  margins  are  then  brought  in 
contact  without  tension  by  a  few  interrupted  sutures  of  fine  silkworm 
gut  or  horse  hair  and  lastly  the  through  and  through  splint  sutures 
are  taken  up  and  tied  over  a  small  roll  of  gauze  tight  enough  to 
afford  some  support  to  the  wound  but  without  undue  tension  which 
will  result  in  cutting  the  tissues.     In  very  fat  wounds  or  in  cases 


320  Appendicitis 

where  there  has  been  contamination  it  is  advantageous  to  pass  several 
very  narrow  strips  of  rubber  dam  down  to  the  muscle  between  the 
sutures  to  provide  drainage  and  lessen  the  liability  of  breaking  down 
of  the  wound. 

The  dressing  of  the  clean  abdominal  wound  is  a  simple  matter. 
The  wound  should  be  covered  by  sterile  gauze  and  a  cotton  pad 
sufficiently  elastic  to  distribute  the  pressure  and  extending  far 
enough  from  the  wound  margins  to  insure  protection.  The  pad 
should  be  held  firmly  in  place  by  adhesive  straps  which  secure  a 
good  grip  on  both  sides.  These  should  not  be  excessively  tight,  but 
snug,  so  as  to  furnish  an  additional  splint  to  the  wound.  The 
straps  should  not  be  drawn  tightly  across  the  upper  abdomen  as 
they  may  impede  respiration.  It  is  not  necessary  to  treat  the  skin 
or  impregnate  the  gauze  with  antiseptics  though  it  cannot  be  said 
that  they  are  harmful  if  used  in  a  strength  that  will  not  cause 
irritation. 

The  hermetical  sealing  of  a  wound  with  silver  foil  or  collodion 
is  inadvisable  since  it  may  prevent  egress  of  the  serous  or  bloody 
oozing  that  occasionally  occurs  and  thus  furnish  a  nidus  for  infection. 

If  drainage  has  been  employed  a  piece  of  flat  gauze  may  be  laid 
over  the  closed  portion  of  the  wound.  A  voluminous  nest  of  crumpled 
gauze  should  then  be  applied  in  contact  with  the  drainage  to  absorb 
the  discharge.  This  should  be  covered  by  a  pad  and  the  whole 
fixed  with  adhesive  straps  as  above  described.  When  a  glass  tube 
is  used  this  should  be  isolated  from  the  remainder  of  the  drainage 
by  bringing  it  out  through  a  perforation  in  the  first  layer  of  gauze 
and  slipping  over  it  a  piece  of  rubber  dam  about  six  inches  square 
through  a  nick  in  the  centre.  A  small  piece  of  gauze  is  laid  over  the 
opening  in  the  tube  and  the  four  corners  of  the  rubber  dam  folded 
over  it  and  secured  by  a  safety  pin  so  as  to  close  it  off  from  the 
remainder  of  the  dressing.  A  narrow  strip  of  selvedge  gauze  may 
with  advantage  be  passed  down  the  tube  to  the  bottom  before  apply- 
ing the  gauze  cap  in  order  to  draw  up  the  secretion  by  capillarity. 
By  arranging  the  tube  in  this  way  it  may  be  inspected  separately 
and  aspirated  at  intervals  to  determine  the  time  for  removal.  In 
order  to  prevent  the  drying  and  coagulation  of  the  exudate  upon  the 
gauze  covering  the  wound,  it  is  at  times  helpful  to  keep  the  gauze 
moistened  with  Wright's  solution  (i  part  sodium  citrate;  4  parts 


Treatment  321 

sodium  chloride  to  100  parts  water).  Over  the  dressing  an  abdom- 
inal binder  or  many-tailed  bandage  should  be  applied  to  equalize 
support  and  prevent  the  patients  from  putting  their  fingers  be- 
neath the  dressings  or  otherwise  meddling  with  them  as  they  will 
occasionally  do. 

I  am  careful  in  all  cases,  but  especially  in  those  where  there 
is  much  subcutaneous  fat  present,  not  to  suture  the  skin  surface 
of  the  wound  too  closely,  but  to  leave  a  half  inch  or  an  inch  between 
the  sutures.  In  every  wound  there  is  normally  a  certain  amount 
of  serum  exuded  from  the  opposed  wound  surfaces,  and  if  no  exit 
for  it  is  allowed  between  the  sutures  it  will  accumulate  beneath 
the  skin,  and  materially  delay  the  healing  of  the  wound.  For  the 
same  reason  I  have  almost  entirely  abandoned  the  subcuticular 
suture,  which  has,  in  my  hands,  only  too  often  caused  the  formation 
of  a  subcutaneous  collection  of  serum,  necessitating  the  too  early 
removal  of  the  suture,  with  consequent  gaping  of  the  skin  wound, 
and  the  production  of  a  more  conspicuous  scar  than  follows  the 
use  of  the  customary  interrupted  or  Glover's  suture.  I  may  add 
that  I  have  seen  similar  unsuccessful  results  from  the  subcuticular 
suture  in  the  hands  of  other  surgeons,  so  that  I  do  not  think  they 
can  justly  be  attributed  to  faults  in  technic. 

When  drainage  is  employed,  the  buried  sutures  are  used  as 
above  described,  but  they  are  made  interrupted,  not  continuous, 
thus  avoiding  the  unpleasant  experience  of  infection  of  one  such 
suture  causing  gaping  of  the  whole  corresponding  layer  of  the 
abdominal  wound.  I  always  prefer  catgut  to  silk.  Splint  sutures 
of  silkworm  gut  are  also  employed,  those  inserted  where  the  drains 
emerge  being  left  long  at  the  ends,  and  looped^  or  clamped  at  their 
tips  by  a  shot,  so  as  to  aid  in  the  repair  of  the  wound  by  being  subse- 
quently tied,  when  drainage  is  dispensed  with.  The  buried  sutures, 
of  course,  extend  only  as  far  as  the  point  of  emergence  of  the  drains. 
In  some  cases  it  is  inadvisable  to  employ  buried  sutures  of  any  kind, 
since  rapid  completion  of  the  operation  is  imperative.  Under 
such  circumstances  the  silkworm  sutures  must  include  all  the 
layers  of  the  abdominal  wall,  even  the  peritoneum;  but  if  after  all 
these  through-and-through  sutures  have  been  introduced  any 
prolongation  of  the  operation  seems  justifiable,  it  will  be  well  to 
apply  a  few  buried  interrupted  sutures  of  chromicized  catgut  to 


322  Appendicitis 

the  aponeurotic  layer,  as  without  such  sutures  the  approximation 
of  this  layer,  on  the  accuracy  of  which  depends  to  a  very  great 
extent  the  subsequent  freedom  from  hernia,  is  at  most  very  im- 
perfect. 

In  cases  in  which  there  is  much  putrid  and  sloughing  matter  in 
the  abdominal  cavity,  which  cannot  be  removed  at  the  time  of  the 
operation,  gauze  as  well  as  tube  drainage  will  have  to  be  employed 
and  the  wound  must  be  left  widely  open.  Yet  it  is  well  to  introduce 
a  few  interrupted  sutures  of  silkworm  gut,  even  if  they  are  passed 
only  through  the  skin  margins,  as  without  some  such  barrier  above 
the  gauze  the  bowels  will  prolapse  into  the  wound.  Such  sutures 
must  be  drawn  tight  enough  only  to  act  as  a  barrier,  and  not  so 
tight  as  to  bring  the  lips  of  the  wound  into  contact. 

In  the  introduction  of  the  buried  sutures  I  use  a  round  needle 
for  the  peritoneum,  straight  if  the  wound  is  large  and  the  walls 
relaxed,  so  that  it  can  be  conveniently  held  in  the  fingers;  but  a 
curved  round  needle  in  other  cases,  using  as  a  needle  holder  a  pair 
of  haemostatic  forceps.  For  the  fascial  stitch  the  ordinary  triangular 
pointed,  curved  surgical  needle  is  used,  it  being  very  diflScult  to 
force  a  round  needle  through  such  dense  tissues.  In  introducing 
the  silkworm-gut  sutures  I  prefer  the  ordinary  straight  surgical 
needle. 

An  accident  sometimes  met  with  in  closing  the  simple  abdominal 
incision  is  a  puncture  with  the  needle  of  one  of  the  deep  epigastric 
veins.  I  am  aware  of  a  case  in  which  such  an  occurrence  led  to 
the  death  of  the  patient  from  haemorrhage.  If  this  accident  occurs, 
the  surgeon  is  not  justified  in  closing  the  wound  until  the  vein  has 
been  ligated.  The  deep  epigastric  veins  can  be  exposed  by 
retracting  the  separated  fibres  of  the  rectus  muscle  then  exposing 
the  transversahs  fascia  between  which  and  the  muscle  the  vessels 
course.  Remembering  this  fact  it  is  a  simple  matter  to  find  and 
ligate  the  injured  vessel.  Some  surgeons  prefer  to  use  a  straight 
round  needle  for  piercing  the  abdominal  wall,  thinking  it  less 
likely  to  cut  the  vessels  just  mentioned. 


Treatment  323 


THE  AFTER-TREATMENT. 

The  after-treatment  of  a  patient  operated  upon  for  appendicitis 
is  of  the  utmost  importance,  and  his  welfare  depends  upon  close 
attention  to  details.  The  general  after-treatment,  applicable  to 
all  cases,  is  the  following:  During  the  period  immediately  following 
the  operation  while  still  under  the  influence  of  the  anaesthetic  the 
patient  should  be  isolated  and  under  the  care  of  a  competent  attend- 
ant, by  which  is  meant  a  physician  or  nurse  who  has  had  special 
experience  in  the  management  of  post-operative  cases.  Neglect 
of  this  precaution  will  occasionally  mean  a  death  from  preventable 
complications.  Immediately  after  operation  the  patient  should 
be  transferred  to  a  warm  bed  and  if  necessary  surrounded  by  several 
hot-water  bags  to  maintain  the  body  warmth,  care  being  taken  to 
avoid  burning  the  skin.  During  this  time  the  patient  should  be  in 
the  supine  position.  His  pulse,  color,  temperature  and  movements 
should  be  carefully  watched  and  any  deviation  from  that  which  is 
recognized  as  usual  and  negligible  by  the  experienced  observer 
should  receive  attention  at  once  and,  if  necessary,  reported  to  the 
surgeon  in  charge  who  should  always  be  within  call.  When  the 
patient  becomes  rational  and  quiet,  attention  may  be  somewhat 
relaxed  but  at  no  time  until  it  is  apparent  that  danger  is  past  should 
frequent  close  observation  be  neglected.  During  the  first  twenty- 
four  or  forty-eight  hours  the  pulse,  respiration  and  temperature 
should  be  taken  every  three  or  four  hours  and  recorded.  Any  other 
observations  of  moment  should  also  be  noted.  If  the  wound  is 
not  tightly  closed  the  dressings  should  be  inspected  occasionally 
for  the  first  few  hours  to  determine  whether  there  is  bleeding. 

The  position  of  the  patient  during  recovery  from  the  ansesthetic, 
if  general  anaesthesia  has  been  employed,  should  be  the  dorsal 
position  as  already  stated.  After  recovery  in  simple  clean  cases  the 
patient  may  assume  either  the  dorsal  or  right  lateral  position,  which- 
ever is  the  more  comfortable.  There  is  no  objection  to  changing 
the  position  occasionally  providing  it  be  done  carefully  by  the  nurse, 
the  patient  being  rolled  passively  over  without  attempting  to  turn 
himself.  The  judicious  use  of  pillows  often  equalizes  support  and 
gives  greater  comfort.     An  experienced  careful  nurse  will  make 


324  Appendicitis 

use  of  hot  and  cold-water  bags,  gentle  massage  of  aching  muscles, 
and  pillow  supports  in  such  a  way  that  the  patient  is  made  comfort- 
able to  a  greater  degree  than  by  an  anodyne. 

After  recovery  from  anaesthesia  all  patients  in  whom  a  general 
diffuse  or  pelvic  peritonitis  is  present  at  the  time  of  operation  should 
be  placed  in  the  sitting  posture.  The  same  position  should  be  used 
when  an  abscess  has  been  opened  transperitoneally  or  the  peritoneum 
otherwise  soiled.  The  back  must  be  maintained  in  an  almost 
straight  position.  The  knees  should  be  flexed,  supported  by  a  pil- 
low and  the  buttocks  supported  so  that  the  maintenance  of  this  po- 
sition does  not  require  any  effort  upon  the  part  of  the  patient. 
Considerable  skill  is  necessary  to  keep  the  patient  in  the  correct 
sitting  position.  Unless  this  is  properly  done  the  patient  will  slide 
down  in  the  bed  and  the  back  become  bent  in  the  lower  dorsal  and 
upper  lumbar  region  so  that  while  he  has  the  appearance  of  sitting, 
examination  will  show  that  the  lower  portion  of  the  abdomen  is 
parallel  with  the  plane  of  the  bed.  In  this  position  the  renal  fossae 
will  not  drain  over  the  brim  of  the  pelvis  and  the  purpose  of  the 
position  is  partially  defeated.  Devices  for  securing  the  correct 
position  are  numerous.  The  specially  made  beds  and  steamer 
chairs  are  eflScient  and  valuable  in  hospital  work  but  are  not 
essential.  A  sling  beneath  the  buttocks  made  by  a  sheet  with  the 
ends  tied  to  the  head  of  the  bed  and  a  pillow  between  this  and 
the  tubera  ischii  will  secure  this  position.  A  triangular  trough 
placed  apex  upward  beneath  the  mattress  will  help  to  keep  the 
patient  from  slipping  and  his  back  may  be  supported  by  the  special 
elevator  On  hospital  beds  or  by  pillows  placed  over  the  back  of  an 
inverted  chair  in  an  ordinary  bed,  or  preferably  by  pillows  them- 
selves. The  sitting  position  should  be  continued  until  the  diffuse 
peritoneal  inflammation  and  exudation,  as  evidenced  by  restoration 
of  peristalsis,  subsidence  of  distention,  and  the  free  passage  of  flatus 
or  faecal  material,  has  entirely  disappeared.  When  it  is  not  possible 
to  have  the  patient  sitting  the  head  of  the  bed  should  be  consider- 
ably raised. 

'  The  purpose  of  this  position  is  to  help  the  gravitation  of  septic 
and  infected  peritoneal  fluids  toward  the  pelvis,  this  being  the  least 
absorbent  and  dangerous  zone  of  the  peritoneal  surface  and  the 
pdiifti  most  available  for  drainage. 


Treatment  325 

The  after-effects  of  ether  generally  encountered  are  nausea  and 
vomiting  and  bronchial  irritation. 

When  the  patient  leaves  the  table  with  much  bronchial  mucus 
the  use  of  oxygen  and  of  small  doses  of  atropine  sulphate  gr.  i-ioo 
once  or  twice  repeated  as  a  rule  does  away  with  the  irritating  lung 
condition.  Excessive  nausea  and  vomiting  are  not  only  annoying, 
but  in  severe  cases  dangerous  since  they  cause  diffusion  of  septic 
material  throughout  the  abdomen.  As  long  as  either  persists  the 
giving  of  fluid  by  the  mouth  is  absolutely  contraindicated.  There 
is  but  one  rational  treatment  for  vomiting  and  it  is  always  successful 
unless  the  vomiting  be  caused  by  severe  toxaemia,  by  general  and 
progressing  peritonitis  or  by  the  presence  of  obstruction.  This  is 
gastric  lavage,  thoroughly  carried  out  and  repeated  until  its  end  has 
been  accomplished. 

Lavage  when  carried  out  upon  patients  having  an  abdominal 
incision  should  always  be  accompanied  by  precautions  regarding 
the  wound.  The  additional  straining  during  the  washing  out  of 
the  stomach  may  cause  damage  to  the  incision  and  therefore  it  is 
important  that  some  additional  support  be  given  it  by  firm  counter- 
pressure  by  the  hands  of  an  assistant. 

Plain  fairly  warm  water  or  salt  solution  should  be  used,  though 
there  is  no  objection  to  the  addition  of  carbonate  of  soda  to  aid  in 
the  removal  of  mucus  from  the  stomach.  I  believe  there  is  always 
a  certain  danger  to  the  gastric  mucosa  in  the  use  of  the  bulb  of  the 
stomach  tube  and  prefer  to  employ  simply  the  siphon  principle.  In 
order  to  be  of  the  greatest  value  lavage  must  be  continued  until 
the  fluid  returns  from  the  stomach  clear  and  clean  with  no  coloring 
matter  or  mucus.  It  must  be  repeated  at  intervals  until  it  has 
fulfilled  its  purpose.  It  is  the  only  treatment  for  vomiting  and  the 
only  preventive  for  that  very  grave  but  fortunately  rare  complica- 
tion, acute  gastric  dilatation. 

The  use  of  drugs  or  external  applications  to  allay  post-operative 
vomiting  is  usually  futile  and  is  to  be  avoided. 

Stimulation  if  necessary  may  be  given  the  patient  in  one  of  several 
ways.  The  use  of  saline — afterward  to  be  mentioned  more  at 
length — is  to  be  commended  in  case  of  emergency.  When  the 
patient  is  in  any  way  shocked  or  depressed  after  operation  the  use 
of  a  saline  enema  of  1000  c.c.  with  the  addition  of  30  c.c.  of  whiskey 


326  Appendicitis 

or  strong  coffee  is  indicated  together  with  diffusible  stimulants,  such 
as  camphorated  oil  in  the  usual  doses.  When  in  an  emergency 
more  rapid  stimulation  is  needed  hypodermoclysis  or  intravenous 
saline  infusion  must  be  used.  The  addition  of  a  small  amount  of 
adrenalin  or  pituitrin  to  the  salt  solution  when  given  intravenously 
aids  in  raising  the  blood  pressure.  The  effect  of  pituitrin  is  some- 
what more  lasting  than  that  of  adrenalin.  I  advise  that  these  drugs 
if  employed  should  be  given  hypodermically  as  their  intravenous 
use  has  been  reputed  in  several  instances  to  have  caused  death. 

Normal  salt  solution  in  conditions  of  great  urgency  may  be  given 
with  advantage  into  a  vein  or  beneath  the  skin.  The  amount  of 
fluid  to  be  introduced  is  to  be  regulated  by  the  gravity  of  the  condi- 
tion and  the  effect  that  its  administration  produces.  On  the  average 
500-1000  c.c.  (1/2  to  I  qt.)  under  the  skin  and  1000-1500  c.c.  (i  to 
I  1/2  qt.)  into  a  vein  should  be  used  for  this  purpose. 

Of  the  drugs  so  commonly  employed  in  this  condition,  strychnia 
is  of  no  value  in  shock  and  digitalis  is  too  slow  in  its  action  to  be  of 
immediate  service.  The  drug,  namely  morphia,  which  is  most 
valuable  in  the  treatment  of  shock  proper  is  the  one  which  unfortu- 
nately should  not  be  employed  in  the  after-treatment  of  appendicitis 
if  avoidable.  When  given  for  this  definite  indication  and  not 
as  a  routine  measure  for  the  comfort  of  the  patient  its  use  is  to  be 
commended 

In  the  absence  of  peritonitis  small  amounts  of  water  or  ice  may 
be  given  within  ten  or  twelve  hours  providing  nausea  has  not  been 
present  for  at  least  six  hours.  Nothing  should  be  introduced  into 
the  stomach  if  the  patient  has  recently  vomited  or  is  in  the  least 
nauseated.  Thirst  is  much  diminished  by  giving  saline  by  rectum, 
which  is  a  wise  practice  even  when  no  peritonitis  exists.  Nourish- 
ment should  be  withheld  until  the  stomach  is  retentive  of  fluid  and 
flatus  is  passed  freely.  I  am  not  at  all  in  sympathy  with  the  practice 
of  giving  water  immediately  after  operation  before  peristalsis  has 
been  established. 

The  first  feedings  should  consist  of  a  dram  or  two  of  albumin 
water,  buttermilk,  tea  or  broths,  which  may  be  given  in  gradually 
increasing  quantities  at  intervals  of  two  or  three  hours,  and  the 
quantity  may  be  so  increased  that  at  the  end  of  the  third  day  six 
or  eight  ounces  are  taken  every  three  hours.     Milk  is  usually  an  un- 


Treatment  327 

satisfactory  food  for  early  administration  on  account  of  its  tendency 
to  cause  flatulence  and  distention.  The  patient  is  kept  on  strictly 
liquid  diet  until  the  bowels  have  been  moved  spontaneously  or  by 
enema  on  the  third  or  fourth  day.  After  that  the  diet  is  increased 
gradually  so  that  at  the  end  of  the  first  week  full  diet  is  taken. 

In  cases  with  localized  abscess  the  same  routine  is  followed 
except  that  the  period  of  liquid  feeding  or  feeding  on  very  soft  foods 
which  produce  little  fascal  residue  is  prolonged  until  practically  all 
drainage  material  has  been  removed  from  the  wound.  This  is 
done  to  minimize  the  chance  of  intestinal  obstruction,  which  is 
rendered  more  likely  by  the  presence  of  considerable  material  within 
the  bowel. 

In  peritonitis,  diffuse  or  general,  nothing  whatever  is  given  by 
mouth  until  peritonitis  has  subsided  and  peristalsis  is  established, 
be  this  twenty-four,  forty-eight,  seventy-two  hours  or  even  longer. 
Then  water  is  given  sparingly  and  liquid  diet  begun  gradually  and 
continued  until  all  danger  is  past.  It  would  be  impossible  to  de- 
prive patients  of  water  and  nourishment  for  so  long  a  period  of  time, 
even  while  assuaging  thirst  by  rinsing  or  wiping  the  mouth  with 
cold  water  were  it  not  for  the  use  of  saline  by  the  bowel. 

Saline  enteroclysis  by  the  continuous  method  of  Murphy  which 
has  been  described  previously  is  the  greatest  advance  in  the  post- 
operative treatment  of  abdominal  conditions  in  the  last  decade. 
I  use  it  as  a  routine  measure  in  all  cases  of  diffuse  peritonitis  and 
by  it  have  been  enabled  in  such  cases  to  reduce  the  mortality 
to  less  than  2%,  a  percentage  unattainable  by  older  methods  of 
after-treatment.  The  saline  thus  given  dilutes  the  toxins  of  the 
blood,  lessens  thirst,  provides  much  needed  fluid,  stimulates  the 
kidneys,  increases  blood  pressure  and  acts  as  a  general  stimulant. 
Locally  it  lessens  absorption  by  the  peritoneum  and  at  times 
seems  to  make  of  the  peritoneum  a  secreting  and  not  an  absorbing 
area. 

The  use  of  continuous  saline  enteroclysis  is  indicated  in  all 
cases  of  appendicitis  where  there  is  infective  exudate  or  fluid  not 
sharply  localized,  when  shock  or  depression  after  operation  is 
marked,  when  there  is  marked  septic  absorption  or  when  the  renal 
function  has  been  impaired.  It  is  an  indispensable  adjunct  in  the 
after-treatment    of    such    cases.     Continuous    saline    enteroclysis 


328  Appendicitis 

should  always  be  employed  unless  there  be  no  attendant  capable  of 
administering  it. 

For  rectal  administration  half-strength  normal  saline  solution 
is  used.  This  is  well  tolerated  by  the  bowel  and  the  absorption 
of  excessive  amounts  of  salt  is  thereby  avoided. 

When  it  is  not  feasible  to  use  this  method  saline  enemas  of 
from  250-500  c.c.  (1/2-1  pt.)  every  three  or  four  hours  may  be 
given  but  do  not  act  nearly  so  well.  The  use  of  nutrient  substances 
in  the  saline  enemata  is  not  usually  necessary.  When,  however, 
the  patient  must  be  deprived  of  food  for  several  days  it  is  helpful 
to  add  small  quantities  of  predigested  beef  and  dextrose.  Whiskey 
also  is  easily  absorbed  through  the  lower  bowel  and  in  some  cases, 
particularly  the  toxic,  is  of  value.  Rectal  alimentation  at  its  best 
is  of  little  moment  and  as  usually  employed  in  the  use  of  undigested 
materials  and  complicated  formulas  is  useless.  As  Paterson  says, 
rectal  alimentation  is  only  another  word  for  starvation. 

The  urine  must  be  carefully  measured  after  operation  and 
should  be  examined  microscopically  and  chemically  daily  for  at 
least  a  week  afterward.  The  amount  is  more  important  than  the 
character.  In  some  patients  catheterization  may  be  necessary  for 
a  day  or  two  after  operation  and  should  be  carried  out  with  the 
strictest  precautions  as  to  cleanliness.  Immediately  after  operation 
the  patient  may  be  allowed  to  go  eight  hours  or  longer  if  the  bladder 
is  not  distended  or  the  patient  uncomfortabe,  before  being  cath- 
eterized,  and  if  it  be  necessary  afterward  it  should  be  done  not 
oftener  than  every  eight  hours  under  ordinary  conditions.  When 
continuous  saline  enteroclysis  is  used  the  amount  of  urine  is  always 
greatly  increased. 

In  patients  who  are  very  toxic,  the  aged  or  debilitated  or  those 
who  have  previously  had  renal  disease  there  may  be  marked  insuffi- 
ciency of  the  kidney  function.  The  quantity  of  urine  is  decreased 
and  albumin  and  casts  becom.e  plentiful.  The  prompt  and  con- 
tinued use  of  saline  by  the  bowel  or  hypodermoclysis  at  intervals, 
aided  if  necessary  by  sparteine,  gr.  1/4  and  caffeine  gr.  1/2  hypo- 
dermically  is  usually  an  aid  in  this  condition,  which  depends, 
however,  more  upon  the  degree  of  toxaemia  present  than  upon  any 
other  factor.  In  almost  every  case  there  is  for  a  few  days  after 
operation  a  slight  quantity  of  albumin  in  the  urine  and  often  we 


Treatment  329 

find  a  few  casts  and  occasionally  sugar  in  small  quantities.  This 
should  not  be  a  cause  for  alarm  unless  there  is  a  concomitant 
marked  decrease  in  the  quantity  of  urine  voided  and  the  condition 
does  not  clear  up  in  a  few  days. 

The  bowels  after  an  operation  for  appendicitis  require  no 
attention  for  three  or  four  days.  Then  an  enema  should  be  given. 
The  bowels  if  sluggish  should -be  moved  routinely  by  enema,  though 
there  is  no  objection  to  an  occasional  dose  of  castor  oil  or  calomel 
in  small  doses  if  the  patient  has  a  foul  mouth  or  coated  tongue. 
Where  peritonitis  is  present  it  is  best  to  use  enemas  only  and  these 
should  be  given  very  gently  so  as  to  ailect  only  the  lower  bowel. 
Enemas  forced  high  in  the  bowel  may  cause  peristalsis  of  the  small 
intestine.  When  the  saline  enteroclysis  is  used  a  cleansing  enema 
will  be  necessary  when  the  fluid  in  the  reservoir  becomes  stained 
showing  that  peristalsis  is  beginning  to  propel  faecal  material  into 
the  lower  bowel. 

With  regard  to  the  special  after-treatment  of  cases  operated 
upon,  they  may,  for  convenience,  be  classified  as  follows:  (i) 
Simple,  uncomplicated  cases  in  which  the  abdominal  wound  is 
completely  closed  at  the  time  of  operation;  (2)  cases  of  local  sup- 
puration in  which  rubber-tube  drainage  has  been  employed,  the 
tube  being  usually  surrounded  with  gauze;  (3)  cases  of  diffuse 
peritonitis. 

I.  In  simple,  uncomplicated  cases,  if  the  temperature  and  general 
condition  of  the  patient  show  no  abnormalities,  the  wound  is  not 
dressed  for  five  or  six  days,  when  the  dressing  should  be  changed, 
the  skin  gently  cleansed  with  alcohol  and  a  sterile  dressing  applied; 
the  sutures  may  be  permitted  to  remain  undisturbed  for  two  or 
more  days  longer,  if  there  is  no  evidence  of  stitch  irritation.  When 
the  sutures  are  of  silkworm  gut  or  horse  hair  they  can  be  removed 
on  the  seventh  or  tenth  day;  if  catgut  is  employed  it  is  not  necessary 
to  remove  it,  but  unless  it  is  absorbed  it  is  well  to  do  so  in  order 
to  remove  a  possible  source  of  irritation.  A  sterile  dressing  of 
gauze  should  still  cover  the  wound  until  every  vestige  of  scab  is 
removed,  and  the  scar  is  firmly  healed.  A  rise  of  temperature  or  a 
decided  increase  in  the  local  pain,  necessitates  immediate  changing  of 
the  dressings  and  a  careful  search  for  the  source  of  irritation. 
Stitch  abscesses  usually  develop  early  and  should  be  opened  and 


T,^o  Appendicitis 

treated  on  general  principles.  If  pus  should  form  within  the 
abdomen,  the  case  alters  its  aspect  and  becomes  one  of  the  following 
classes. 

The  patient  may  be  allowed  to  leave  his  bed  at  the  end  of  a  week, 
or  even  in  some  cases  as  early  as  the  fifth  or  sixth  day,  where  the 
incision  has  been  a  small  one.  For  the  first  week  or  ten  days  after 
the  patient  begins  to  move  about,  his  abdominal  wall  should  be 
supported  by  an  ordinary  circular  bandage  or  broad  adhesive  straps. 
I  have  stated  elsewhere  that  I  do  not  consider  abdominal  supporters 
of  much  value,  except  perhaps  when  the  incision  has  been  unusually 
large  or  left  unsutured  at  the  time  of  operation  for  the  purpose  of 
drainage. 

2.  Cases  with  local  suppuration  and  drainage  by  tube,  gauze  or 
both,  may  require  stimulation  as  previously  mentioned.  In  some  of 
these  cases  it  will  be  found  necessary  to  continue  the  use  of  stimu- 
lants, tonics,  and  especially  nutritious  diet,  for  a  considerable  time. 
In  depressed  states  massage,  oil  rubs,  sun  baths  and  fresh  air  are 
often  very  helpful. 

The  dressings,  in  cases  of  local  suppuration,  need  not  be  dis- 
turbed until  the  third  or  fourth  day  after  the  operation,  unless  the 
outer  dressings  have  become  soiled  by  the  discharge  from  the  wound, 
or  unless  some  unfavorable  sympton  makes  earlier  inspection  of  the 
wound  advisable.  In  case  the  outer  dressing  does  become  soiled, 
it  should  be  changed  immediately,  and  in  some  cases  it  is  necessary 
to  do  this  twice  daily.  The  dressing  in  immediate  contact  with  the 
dischaiging  surface  should  be  moistened  with  Wright's  solution 
(i  part  sodium  citrate,  4  parts  sodium  chloride  to  100  parts  water) 
to  facilitate  exudation.  The  outer  dressings  should  be  kept  dry. 
When  the  dressings  remain  saturated  with  blood  or  serum  or  even 
with  purulent  exudate,  bacteria  may  rapidly  infect  by  continuity. 
As  a  rule  at  the  end  of  the  third  or  fourth  day  these  outer  dressings 
must  be  removed  and  the  skin  surrounding  the  wound  gently 
cleansed.  Only  in  exceptional  cases  should  any  of  the  gauze  pack- 
ing be  removed  this  early.  The  too  early  removal  of  gauze  packing 
frequently  produces  disastrous  results  by  opening  avenues  by  which 
infection  may  extend  to  the  surrounding  coils  of  bowel,  causing  a 
peritonitis  or  secondary  pus  collection.  In  addition,  fully  formed 
granulations    are  crowded  with  leucocytes  preventing  absorption, 


Treatment  331 

and  if  the  bowel  surface  is  injured  too  early  by  the  removal  of 
gauze  such  protection  is  not  afforded.  If  the  case  is  one  where  an 
appendiceal  abscess  was  opened  extra-peritoneally,  little  or  no  gauze 
will  have  been  used  around  the  tube;  in  such  cases  it  may  be  well  to 
remove  this  gauze  at  the  first  dressing,  and,  having  cleansed  the  tube, 
to  replace  it  with  less  gauze,  allowing  the  abscess  cavity  to  close 
gradually  by  the  pressure  of  the  neighboring  coils  of  bowel.  But 
where  a  coffer-dam  of  gauze  has  been  used,  the  adhesions  between 
the  surrounding  loops  of  bowel  will  not  be  sufficiently  firm  at  the  end 
of  three  or  four  days  to  ensure  the  general  peritoneal  cavity  from 
infection  if  the  protecting  gauze  is  removed;  and  besides  this  con- 
sideration the  too  early  removal  of  the  gauze  is  very  painful  to  the 
patient,  and  is  apt  to  cause  bleeding  from  the  adherent  bowels. 
After  five  to  eight  days,  however,  it  will  be  found  that  the  granula- 
tions on  the  peritoneal  surfaces  in  contact  with  the  gauze  have 
reached  such  a  stage  of  development  that  usually  the  gauze  may  be 
removed  with  little  pain  and  considerably  greater  facility  than  at  an 
earlier  date.  Before  attempting  the  removal  of  the  gauze,  each 
piece  in  turn  should  be  thoroughly  saturated  with  warm  normal 
saline  solution,  sterile  water,  or  boracic  acid  solution;  and  in  their 
removal  neither  haste  nor  force  should  have  any  place.  Unless  their 
removal  proceeds  with  the  utmost  gentleness,  the  protective  adhesions 
may  be  torn,  or  the  bowel  or  omentum  may  be  dragged  into  the 
wound.  Even  when  the  greatest  care  is  exercised  this  may  occur 
once  in  a  great  while.  If  it  does,  the  bowel  or  omentum  should  be 
replaced  and  held  in  position  by  pieces  of  sterile  gauze  until  the 
remaining  gauze  has  been  removed.  It  is  sometimes  wise  not  to 
attempt  the  removal  of  all  the  gauze  at  the  first  sitting,  but,  after 
thoroughly  saturating  the  most  firmly  fixed  pieces,  again  to  attempt 
their  removal  after  the  lapse  of  eight  or  twelve  hours.  It  is  not 
necessary  to  irrigate  the  abscess  cavity,  but  the  pus  should  be  care- 
fully mopped  away.  The  tube  should  be  replaced  if  there  is  anything 
further  to  be  drained ;  but  as  a  rule  all  that  is  required  after  the  first 
week  or  ten  days  is  to  keep  the  wound  open  and  allow  it  to  heal  by 
granulation  from  the  bottom. 

In  those  rare  cases  where  a  cigarette  drain  has  been  employed, 
without  a  tube,  and  where  there  was  practically  nothing  to  drain, 
it  is  usually  well  to  remove  this  gauze  plug  on  the  second  or  third  day. 


332  Appendicitis 

If  no  bad  odor  is  present,  and  the  gauze  is  practically  unsoiled  the 
subsequent  management  of  such  cases  is  the  same  as  that  of  those 
where  the  wound  was  completely  closed  at  the  time  of  operation; 
but  extra  attention  should  be  paid  the  case  on  account  of  the  possi- 
bility of  suppuration  progressing  beneath  the  wound. 

3.  In  cases  where  at  the  time  of  operation  there  was  diffuse 
peritonitis  and  exudate  drainage  will  have  been  employed  either  by  a 
glass  or  rubber  tube  extending  to  the  pelvis,  supplemented  occasion- 
ally by  wicks  of  gauze.  It  is  my  practice  to  place  the  patients  in  bed 
in  a  semi-sitting  posture  and  give  continuous  enteroclysis.  All 
nourishment  by  the  mouth  must  be  withheld  for  the  time  being, 
and  ice-bags  placed  over  the  abdomen  for  the  patient's  comfort. 

If  a  glass  tube  has  been  employed,  its  extremity  should  project 
beyond  the  other  dressings,  and  should  be  covered  with  sterile 
rubber  tissue  containing  a  gauze  sponge  to  absorb  any  fluids  that 
may  be  drained  out  by  the  capillary  action  of  the  gauze  wick  placed 
in  the  interior  of  the  tube.  In  addition,  the  nurse  in  attendance 
should  be  provided  with  a  long-nozzled  syringe  (a  rubber  tube 
attached  to  the  nozzle  of  an  ordinary  syringe  will  answer  the  purpose) 
to  suck  up  from  the  pelvis  through  the  glass  drainage  tube  any 
purulent  material  that  accumulates.  During  the  first  eight  to  twelve 
hours  the  glass  drainage  tube  should  be  exhausted  every  few  hours, 
according  to  the  amount  of  fluid  that  accumulates.  During  the 
intervals  a  strip  of  gauze  should  be  re-inserted  through  the  drainage 
tube  into  the  pelvis,  and  it  will  commonly  be  found  that  some,  at  least, 
of  the  extravasated  matters  are  absorbed  in  this  manner  into  the 
gauze  covering  the  outer  extremity  of  the  glass  tube.  The  most 
painstaking  care  should  be  taken  not  to  further  contaminate  the 
peritoneal  cavity.  To  this  end  the  suction  apparatus  should  be 
repeatedly  sterilized,  and  the  nurse's  hands  should  be  surgically 
cleansed  each  time  the  tube  has  to  be  exhausted.  During  the  first 
twelve  or  twenty-four  hours  the  amount  of  fluid  which  collects  in  the 
pelvis  will  be  found  to  gradually  diminish,  until  on  the  second  day 
it  will  usually  be  necessary  to  exhaust  the  drainage  tube  only  every 
three  or  four  hours,  and  subsequently  at  even  greater  intervals. 
At  each  dressing  the  tube  should  be  given  a  half  turn  to  loosen  any 
adhesions  which  the  omentum  or  bowel  may  have  formed  to  the 
fenestrations  of  the  tube.     When  the  amount  of  fluid  becomes  insig- 


Treatment  333 

nificant  and  of  a  straw  color — usually  on  the  second  or  third  day — - 
the  glass  tube  may  be  removed,  and,  if  necessary,  a  rubber  tube  of 
smaller  calibre  substituted,  introducing  the  rubber  tube  through  the 
glass  tube  before  the  latter  is  removed.  The  periodical  exhaustion 
of  the  tube  may  then  be  discontinued.  A  rubber  tube  is  generally 
much  less  irksome  to  the  patient  than  one  of  glass  and  after  the 
peritoneal  discharge  has  nearly  ceased,  drains  equally  well.  The 
rubber  tube  is  to  be  withdrawn  gradually  cutting  off  an  inch  or 
two  at  each  dressing. 

If  gauze  drainage,  either  in  conjunction  with  a  glass  tube  or 
without  one,  has  been  employed  in  these  cases,  it  should  not  be 
disturbed  for  five  to  ten  days,  except  to  loosen  it  if  the  discharge  is 
dammed  back.  In  these  cases,  even  more  than  where  the  suppura- 
tion is  localized,  are  skill  and  dexterity  requisite  to  dress  the  wound, 
and  to  prevent  the  prolapse  of  the  bowel  or  omentum.  Great  care 
must  be  exercised  in  replacing  the  gauze,  on  the  one  hand  not  to 
leave  any  suppurating  pockets  undrained,  nor  on  the  other  to 
produce  intestinal  obstruction  by  packing  the  abscess  cavity  too 
tightly.  The  management  of  the  pelvic  tube  is  the  same  in  these 
cases  as  in  those  when  no  gauze  has  been  employed. 

APPENDICOSTOMY. 

Appendicostomy  consists  in  the  establishment  of  a  fistula 
through  the  appendix  into  the  caecum,  the  chief  object  being  to 
afford  a  means  for  the  introduction  of  fluids  into  the  large  bowel 
(Russ). 

The  operation  has  been  employed  to  accomplish  the  irrigation 
of  the  colon  in  various  forms  of  disease  of  that  portion  of  the  intes- 
tine and  occasionally  to  meet  certain  other  indications  arising  from 
abdominal  disease  or  operative  procedures. 

It  has  found  by  far  its  greatest  usefulness  in  the  treatment  of 
amoebic  dysentery,  mucous  colitis  and  ulcerative  conditions  of  the 
colon.  Berry  and  Whitmore  had  most  excellent  results  in  true 
chronic  dysentery,  six  of  ten  patients  recovering.  As  early  as  1905 
Willy  Meyer  reported  his  excellent  results  in  cases  of  amoebic  dysen- 
tery and  ulcerative  colitis.  Tuttle  states  that  of  forty-four  cases  of 
chronic  amoebic  dysentery  treated  by  appendicostomy,  thirty-eight 
recovered.     Russ  reported  two  cases  in  his  own  practice  with  most 


334  Appendicitis 

encouraging  results.     Gaut  speaks  favorably  of  his  own  results  in 
dysentery  and  colitis. 

Keetley  in  an  exhaustive  review  of  the  subject  states  that  the 
operation  has  been  used  in  dysentery,  colitis,  intestinal  haemorrhage, 
after  enterectomy  and  colectomy  for  intestinal  distention  of  toxaemia, 
in  cases  of  malnutrition  or  chronic  constipation  and  in  pernicious 
anaemia.  He  himself  reported  a  case  in  1905  in  which  the  operation 
was  performed  upon  a  child  after  the  reduction  of  an  intussuscep- 
tion to  anchor  the  caecum,  for  lavage  of  the  intestine  and  for  the 
possible  injection  of  saline  in  case  of  collapse.  The  same  author 
also  employed  appendicostomy  in  cases  of  typhoid  fever. 

The  technic  of  appendicostomy  is  simple.  Making  an  incision 
through  the  rectus  muscle  as  for  an  appendectomy  (Keetley,  Meyer) 
or  a  muscle  splitting  or  McBurney  incision  (Rodman  and  Anders) 
(Russ)  the  appendix  is  brought  into  view.  Barry  and  Whitmore 
state  that  the  operation  may  be  readily  performed  under  local 
anaesthesia.  The  appendix  is  placed  straight  through  the  incision 
(or  obliquely,  Keetley,  Meyer),  and  the  caecum  stitched  to  the  peri- 
toneum. Certain  operators  lay  stress  upon  going  through  the 
meso-appendix  and  not  around  the  appendiceal  artery,  others 
state  that  this  is  an  unimportant  detail  provided  that  that  portion 
of  the  appendix  beyond  the  tied  off  appendiceal  artery  be  brought 
out  of  the  wound.  The  appendix  having  been  brought  out  through 
the  incision,  the  latter  is  closed  by  layer  sutures  leaving  the  tip  of  the 
appendix  exposed.  The  actual  opening  into  the  appendix  may  be 
made  at  once  or  twenty-four  to  forty-eight  hours  afterward  as  a 
secondary  operation;  the  latter  seems  to  be  the  method  most  favored 
by  those  experienced  in  the  technic  of  the  operation.  The  appen- 
diceal fistula  having  been  made,  irrigation  of  the  colon  may  be  per- 
formed by  means  of  a  small  catheter  passed  into  the  lumen  of  the 
appendix.  After  appendicostomy  has  been  performed  the  only 
serious  accident  that  might  occur  is  the  slipping  back  of  the  caecum 
and  the  appendix,  as  in  the  case  reported  by  Meyer.  Usually  there 
is  no  difficulty  in  closing  the  fistula;  indeed,  the  difficulty  in  cases  of 
appendicostomy  is  rather  to  keep  the  lumen  of  the  appendix  open 
as  it  shows  a  great  tendency  to  close  spontaneously. 

Personally  this  operation  has  never  appealed  to  me  strongly. 
With  the  exception  of  amoebic  dysentery  and  perhaps  a  few  cases  of 
colitis  its  field  of  usefulness  I  think  is  very  small. 


COMPLICATIONS  AND  SEQUELS. 

The  complications  and  sequels  of  appendicitis  are  many  and 
varied.  Some  of  them — as  circumscribed  peritonitis,  for  example 
— are  in  many  respects  rather  a  part  of  the  disease  than  one  of  its 
complications;  others,  as  diffuse  peritonitis,  gangrene  of  the  bowel, 
abscess  of  the  liver,  etc.,  are  of  much  more  serious  moment,  and 
greatly  interfere  with  the  prompt  recovery  of  the  patient,  or  cause 
a  fatal  issue;  others,  which  may  or  may  not  pertain  to  either  of  the 
foregoing  classes  are  of  importance  only  as  they  render  more  or 
less  difficult  the  proper  surgical  treatment  of  the  affection. 

It  is  thus  convenient  to  divide  a  consideration  of  the  compli- 
cations and  sequels  into:  (i)  The  complications  due  to  the  disease 
itself.     (2)  The  sequels  of  the  operation. 

Such  a  division  must  occasionally  be  somewhat  arbitrary,  as, 
for  example,  the  occurrence  of  intestinal  obstruction  which,  follow- 
ing operation,  is  nearly  always  due  to  the  peritonitis  produced  by 
the  escape  of  infection  from  the  appendix;  or  faecal  fistula,  which 
may  occasionally  occur  where  no  operation  has  been  performed 
and  which  is  almost  always  caused  by  local  necrosis  of  a  caecum 
infected  by  a  diseased  appendix.  The  post-operative  complica- 
tions in  the  last  2400  cases  of  acute  appendicitis  have  been  carefully 
compiled.  Of  these,  1997  cases  occurred  in  the  German  Hospital 
and  were  in  adults,  and  403  cases  were  in  children  under  treatment 
at  the  Mary  J.  Drexel  Home.  These  cases  are  tabulated  at  the 
end  of  the  chapter. 

COMPLICATIONS  OF  APPENDICITIS. 

Of  the  complications  that  pertain  to  the  disease  itself  peri- 
tonitis is  the  most  frequent,  and  the  most  important.  In  every 
case  of  acute  appendicitis  the  peritoneum  reacts  to  the  irritant  and 
secretes  a  serous  effusion,  the  quantity  of  which  depends  upon  the 
amount  and  virulence  of  the  bacteria  or  their  toxins,  or  both.  Nature 
then  offers  two  measures  by  which  the  process  may  be  rendered 

335 


336  Appendicitis 

harmless  and  the  patient  recover.  The  first  and  most  common  is 
by  the  formation  of  protecting  and  encircling  adhesions  which  tend 
to  confine  the  infection  to  a  localized  area.  The  other  method 
consists  in  the  peritoneum  reacting  to  the  irritant  by  effusing  from 
its  surface  an  amount  of  fluid  and  phagocytes  proportionate  to  the 
irritation,  diluting  the  toxins  and  furnishing  antibodies  and  phago- 
cytic cells  which  endeavor  to  check  bacterial  invasion.  The  anti- 
toxic action  of  this  effusion  explains  the  rapid  recovery  of  the  peri- 
toneum from  infection  after  removal  of  the  appendix,  if  operation 
is  performed  early.  The  five  most  frequent  locations  of  local  sup- 
puration have  already  been  described  in  the  chapter  on  Treatment, 
and  the  procedures  proper  to  be  employed  in  each  case  have  there 
been  discussed  in  considerable  detail;  so  that  it  is  unnecessary  to  do 
more  here  than  urge  the  importance  of  evacuating  all  such  abscesses 
at  the  earliest  possible  moment,  so  as  to  prevent  sepsis  and  second- 
ary perforation  of  the  intestinal  tract.  Diffuse  suppurative  peri- 
tonitis is  a  much  more  fatal  complication.  It  occurs  under  two 
chief  forms,  as  already  described  in  the  chapter  on  Pathology.  In 
the  first  many  adhesions  are  formed,  and  small  abscesses  arise  here 
and  there  between  the  intestinal  coils;  in  the  second,  few  if  any 
adhesions  are  present,  and  the  intestines  float  free  in  a  bath  of  pus. 
At  times  a  dry  peritonitis  is  encountered  without  adhesions.  This 
form  is  usually  due  to  the  streptococcus  and  is  peculiarly  virulent. 

In  certain  of  the  suppurative  and  gangrenous  cases  of  appendi- 
citis, and  particularly  when  the  abscess  of  the  appendix  lies  behind 
or  to  the  outer  side  of  the  caecum  or  colon,  the  surrounding  tissues 
will  be  found  partially  or  completely  gangrenous.  This  retro- 
peritoneal form  of  sepsis  is  an  infection  by  continuity,  and  not  by 
way  of  the  lymphatics;  since,  as  is  well  known,  the  lymphatics  of 
the  appendix  do  not  empty  into  the  retro-peritoneal  tissues  in  this 
situation,  but  pass  to  lymph  glands  lying  in  the  angle  between  the 
ileum  and  the  colon  and  along  the  ascending  colon.  In  cases  where 
the  disease  presents  this  type,  the  wound  must  be  treated  as  an  open 
one,  as  has  been  fully  described  when  discussing  the  operative  technic 
for  appendicitis.  The  retro-peritoneal  lymphatics  when  infected 
may  result  in  peri-pancreatic  inflammation  and  abscess  of  the 
pancreas,  as  I  have  seen. 

Bowel  necrosis  is  a  very  serious  complication  of  appendicitis. 


Complications  and  Sequels  337 

The  appendix  may  perforate  directly  into  the  caecum  or  another 
portion  of  the  intestinal  tract  to  which  it  has  become  adherent;  or 
an  abscess,  formed  around  the  appendix,  may  rupture  into  some 
portion  of  the  intestinal  canal;  or,  where  diffuse  suppurative  peri- 
tonitis exists,  with  multiple  abscesses  among  the  intestines,  any  one 
of  these,  or  several  of  them,  may  ulcerate  into  the  neighboring 
intestine,  and  a  faecal  fistula  will  thus  be  formed  even  before  an 
operation  is  undertaken.  Instances  of  perforation  into  the  duo- 
denum, ileum,  caecum,  colon,  sigmoid  flexure  and  rectum  have  been 
reported.  In  2400  cases  necrosis  of  the  bowel  was  observed  in 
twenty-one  instances,  of  which  twelve  recovered  and  nine  died. 

A  diseased  appendix  or  a  collection  of  pus  about  an  appendix 
may  be  in  relation  with,  and  give  rise  to  necrosis  of  the  iliac  blood- 
vessels. The  vein  is  more  likely  to  become  involved  in  the  inflam- 
matory process  th-an  is  the  artery,  probably  for  the  two  reasons  that 
its  coats  are  thinner,  and  the  blood  within  it  circulates  less  rapidly. 
Whichever  vessel  be  involved,  perforation  of  the  vessel  with  fatal 
haemorrhage  may  ensue.  Secondary  hcemorrhage  of  this  type  may 
follow  incision  and  drainage  of  an  abscess,  though  fortunately  this 
is  a  rare  complication.  The  haemorrhage  may  be  controlled  by 
gauze  packing  or  failing  this,  operation  and  ligation  of  the  bleeding 
vessel  must  be  resorted  to,  Pevvel  has  recorded  a  case  of  perfo- 
ration of  the  external  iliac  artery.  It  is  more  common,  however, 
for  an  arteritis  or  a  phlebitis  to  occur.  This  results  in  thrombo- 
arteritis  or  thrombo-phlebitis,  which  may  give  rise  to  embolic  pro- 
cesses. Schelbenzuber  has  reported  an  unusual  case  of  embolism 
of  the  left  anterior  tibial  artery  with  consequent  gangrene  of  the  leg, 
and  Berard  a  case  of  obliteration  of  the  right  crural  artery,  the  result 
of  arteritis.  Of  the  venous  involvements  may  be  mentioned  inflam- 
mation of  the  right  iliac  vein,  of  the  right  femoral  vein,  of  the  left 
femoral  vein,  of  the  mesenteric  veins,  and  of  the  portal  vein.  Inflam- 
mation of  the  veins  of  the  extremities  is  not  so  rare  from  other  causes 
as  to  require  illustration  in  this  connection.  Mesenteric  thrombosis 
has  already  been  discussed  in  the  chapter  on  Differential  Diagnosis. 
Eleven  of  2400  cases  are  recorded  as  having  had  phlebitis  after 
operation. 

Inflammation  of  the  portal  vein,  however,  with  a  consequent 
suppurative  hepatitis,   is  not  very  infrequently  seen.     These  in- 


338  Appendicitis 

flammations  are  infectious,  and  give  rise  to  infectious  embolic 
processes,  which  are  met  with  under  the  forms  of  hepatic  abscess 
and  suppurative  pylephlebitis.  Occasionally  these  conditions 
co-exist,  as  in  the  following  case: 

A.  T.,  a  white  male,  aged  twenty-two  years  and  a  bartender  by  occupation, 
had  a  negative  family  history.  His  previous  personal  history  was  also  negative 
— he  had  had  only  the  ordinary  diseases  of  childhood.  During  the  eighteen 
months  prior  to  first  observation  he  had  had  three  or  four  attacks  of  colic, 
attended  by  vomiting.  There  was  no  recollection  of  localized  pain.  These 
attacks  usually  subsided  within  a  few  days  and  he  was  able  to  return  to  his  work. 

On  March  i,  he  developed  a  sore  throat,  which  was  accompanied  by  stiffness 
of  all  his  extremities  and  was  followed  by  excruciating  griping  pains  in  the  epi- 
gastrium, which  were  increased  by  deep  inspiration.  He  had  chills,  fever,  and 
sweats  at  irregular  intervals;  headache  and  backache;  his  appetite  was  fair  and 
his  bowels  were  loose.  When  seen  by  his  attending  physician  on  March  15th, 
he  presented  the  following  symptoms:  Temperature,  103.4°  F.;  pulse-rate  96; 
hectic  flush  on  the  cheeks;  extreme  pain  and  tenderness  and  slight  tympany  in 
the  epigastrium.  His  tongue  was  thickly  coated;  his  heart  and  lungs  were 
Qormal.  His  urine  contained  a  trace  of  albumin  and  a  few  granular  casts. 
Blood  examination  revealed  the  normal  number  of  erythrocytes  and  leucocytes, 
and  the  normal  percentage  of  haemoglobin.  Microscopically,  a  few  intracellular 
organisms,  resembling  the  hajmatozoa  of  malaria,  were  found.  During  the 
succeeding  night  he  had  a  severe  chill  and  profuse  sweating.  The  following 
morning  at  5  A.  M.  his  temperature  was  98°  F.  and  his  pulse-rate  was  80.  A 
serous  diarrhoea  then  set  in.  Quinine  was  administered  without  relief,  and  no 
change  in  his  symptoms  was  noted  until  March  19th,  when,  with  a  morning 
temperature  of  96.6°  F.,  his  pulse-rate  was  104.  His  pulse  was  irregular,  there 
was  general  abdominal  distention,  accompanied  by  marked  tenderness  and 
tympany,  and  a  general  peritonitis  had  evidently  supervened.  The  diarrhoea 
continued,  the  pulse  was  rapid  and  irregular,  and  the  patient  grew  weaker,  and 
died  April  4th.  At  necropsy,  performed  eight  hours  after  death,  there  was 
detected  a  general  peritonitis  due  to  a  ruptured  abscess  of  the  liver.  The 
appendix  was  perforated  and  was  embedded  in  a  mass  of  necrotic  adhesions. 
There  was  purulent  inflammation  of  the  portal  vein  extending  into  the  liver 
substance.  In  the  upper  part  of  the  right  lobe  of  the  liver  there  were  numerous 
embolic  abscesses,  one  of  which,  situated  near  the  surface,  had  ruptured  beneath 
the  diaphragm. 

This  case,  which  came  under  my  observation  at  necropsy  only, 
is  reported:  (i)  To  demonstrate  the  importance  of  excluding 
primary  appendicular  inflammation  in,  the  diagnosis  of  all  intra- 
abdominal affections,  particularly  when  pain  and  tenderness  are 
not  referred  to  the  right  iliac  fossa;  and  (2)  to  emphasize  the  value 


Complications  and  Sequels  339 

that  should  be  attached  to  a  history  of  previous  attacks  of  colic 
with  gastric  irritation,  as  indicating  early  involvement  of  the  appen- 
dix— from  which  as  an  infectious  focus  other  organs  may  subse- 
quently become  involved. 

Unfortunately  fatal  suppurative  hepatitis  may  occasionally 
follow  even  comparatively  early  removal  of  the  appendix,  if  time 
has  elapsed  sufficient  for  perforation  of  the  walls  of  the  appendix 
by  the  infecting  bacteria. 

C.  L.,  colored,  age  twenty-eight  years.  Family  and  personal  history  good. 
Present  trouble  started  thirteen  days  before  admission  to  German  Hospital 
November  30th,  1904,  with  acute  paroxysmal  pain  over  right  abdomen,  radiating 
to  pit  of  stomach.  Paroxysms  every  ten  to  fifteen  minutes  for  eighteen  hours, 
pain  then  became  localized  to  right  iliac  fossa  and  gall-bladder  region.  Bowels 
opened  by  oil  and  enema.  Patient  vomited  five  or  six  times.  Three  days 
later  he  began  to  become  jaundiced,  gradually  increasing  to  a  deep  yellow  color. 
Stools  clay  color;  tongue  coated. 

Examination  showed  rigidity  of  entire  right  abdomen,  tenderness  over  appen- 
dix and  gall-bladder  region;  slight  distention,  liver  dullness  decreased,  probably 
from  gas.     Had  a  slight  cough  and  few  rales  over  base  of  right  lung. 

Operation. — Incision  well  toward  spine  of  ilium;  peritoneum  opened  over  a 
small  abscess.  Pus  sponged  out  and  faecal  concretion  removed.  Abscess 
cavity  packed  with  iodoform  gauze.     The  patient  died  in  a  few  days. 

Pathological  Report.  Special  Observations. — Peritoneal  cavity  showed  no 
free  pus.  Appendix  was  found  somewhat  anterior  and  pointing  straight 
toward  the  pubis.  It  was  gangrenous,  about  6  cm.  long  and  showed  a  large 
perforation  at  its  middle.  There  was  a  small  pus  pocket,  containing  a  few 
drops  of  pus,  at  this  point.  The  colon  at  and  above  the  ileo-caecal  valve 
showed  beneath  serosa  small  areas  of  purulent  material  up  to  almost  the 
transverse  colon.  Upon  opening  it  there  was  found  a  purulent  and  ulcera- 
tive colitis,  extending  up  almost  ten  inches.  Small  intestine  congested.  The 
mesenteric  glands  were  enlarged.  Superior  mesenteric  veins  in  some  places 
on  section  showed  pus  because  of  a  phlebitis.  Spleen  slightly  enlarged  and 
much  congested.  Liver  very  much  enlarged  and  a  hand's-breadth  below  the 
costal  margin.  Weight  3600  grammes.  A  curious  extension  of  the  left  lobe 
was  noted  as  a  very  flat  portion.  The  surface  and  interior  of  the  liver  showed 
multiple  abscess  formation,  the  abscesses  being  not  yet  well  defined  or  broken 
down.  The  veins  showed  a  phlebitis.  Gall-bladder  normal.  Lungs:  the 
lower  lobe  of  the  right  lung  was  very  pale  with  many  anthracotic  spots. 
Kidneys:   right,  normal,  very  pale;   left,  enlarged  and  pale. 

The  subjects  of  hepatic  abscess  and  pylephlebitis  have  been 
studied  by  Pellegrini,  by  D,  F,  Jones  and  by  A,  K.  Gerster.     From 


340  Appendicitis 

various  authorities  quoted  by  these  writers  it  appears  that  suppura- 
tive pylephlebitis  or  hepatic  abscess  occurs  in  from  i  to  2  per  cent, 
of  all  cases  of  acute  appendicitis,  and  that  of  all  intestinal  lesions 
inflammation  of  the  appendix  is  the  most  frequent  cause.  At  the 
present  time  these  figures  are  certainly  too  high  due  to  the  practice 
of  early  operation  before  the  inflammation  has  seriously  attacked 
the  efferent  veins.  Still  it  is  a  complication  to  be  reckoned.  If 
the  whole  portal  vein  becomes  the  seat  of  septic  thrombosis  the 
inflammatory  process  spreads  to  its  minutest  branches  in  the  liver, 
forming  a  true  suppurative  pylephlebitis,  as  in  the  case  just  recorded. 
If,  however,  a  single  embolus  lodges  in  the  liver  only  one  abscess  is 
formed  at  first,  though  others  may  arise  either  by  subsequent 
emboli  becoming  lodged,  or  by  extension  from  the  original  focus 
of  suppuration  in  the  liver.  Infection  of  the  liver  is  probably 
always  produced  by  way  of  the  portal  system,  as  the  retro-peritoneal 
lymphatics  do  not  drain  into  the  liver;  this  is  well  shown  by  the 
rarity  of  liver  abscess  as  a  complication  of  appendicitis  where  the 
appendix  lies  in  the  retro-caecal  cellular  tissue,  or  even  in  contact 
with  the  liver;  also  in  cases  of  peri-nephric  abscess.  Moreover,  the 
superficial  lymphatics  of  the  liver  itself  drain  from  its  centre  to- 
ward the  periphery  like  the  bile  and  do  not  pursue  a  centripetal 
course  as  does  the  blood  in  the  portal  vein. 

The  symptoms  most  to  be  relied  on  in  the  diagnosis  of  suppu- 
rative hepatitis  are  the  following :  First  and  foremost,  it  is  important 
to  learn  the  history  of  the  case,  to  detect  if  possible  a  preceding 
appendicitis,  or  any  disease  simulating  its  usual  symptoms,  since 
in  many  cases  pylephlebitis  follows  an  attack  of  appendicitis  which 
has  passed  entirely  unnoticed.  Rarely  will  any  symptoms  referable 
to  the  liver  be  detected  earlier  than  the  fifth  or  sixth  day,  and  they 
may  be  delayed  for  several  weeks.  If,  however,  a  patient  known 
to  have  had  appendicitis,  presents,  after  a  suitable  interval  of  time, 
sudden  epigastric  or  right  hypochondriac  pain,  with  a  chill,  and 
develops  tenderness  over  the  liver,  with  perhaps  pain  on  deep 
inspiration,  and  jaundice,  hepatic  complications  should  be  suspected. 
Special  attention  is  called  by  Gerster  to  the  frequency  with  which 
this  dreaded  complication  results  from  operations  performed  even 
after  the  acute  attack  has  subsided,  and  thorough  postmortem 
examinations  are  suggested  in  such  cases  in  order  that  if  possible 


Complications  and  Sequels  341 

undeserved  blame  should  be  removed  from  the  operator  who  has 
had  the  misfortune  to  operate  upon  a  patient  with  a  septic  thrombus 
which  is  ready  to  be  detached  and  carried  into  the  portal  circulation 
on  the  slightest  provocation.  It  may  be  difficult  at  times  to  exclude 
a  right-sided  pleurisy  or  pneumionia;  an  examination  of  the  blood 
should  be  made  to  exclude  malaria;  while  careful  physical  examina- 
tion will  usually  render  evident  the  absence  of  malignant  endocarditis 
and  miliary  tuberculosis.  All  of  these  diseases  are  liable  to  present 
somewhat  similar  symptoms.  Tenderness  on  deep  pressure  over 
the  liver  is  the  most  valuable  local  sign;  occasionally,  if  the  hepatic 
abscess  contains  gas,  a  tympanitic  note  may  be  obtained.  Puncture 
or  aspiration  of  the  liver  for  the  purpose  of  detecting  suppuration 
is  a  dangerous  as  well  as  an  uncertain  method  of  making  a  diag- 
nosis. Even  puncture  of  the  exposed  liver  will  frequently  fail  to 
reveal  the  presence  of  pus,  although  a  good-sized  abscess  be  present. 

At  a  later  stage  the  pain  and  tenderness  are  often  diminished; 
diarrhoea  may  set  in,  jaundice  may  be  detected,  and  there  may  be 
bile  in  the  urine.  If  numerous  chills  occur  it  is  extremely  probable 
that  the  affection  is  a  suppurative  pylephlebitis,  and  not  a  single 
abscess  of  the  liver,  since  each  new  extension  of  infection  almost 
invariably  produces  a  rigor.  The  temperature  is  extremely  irregu- 
lar, varying  from  100°  F.  to  104°  F.  In  the  later  stages  of  the  dis- 
ease the  fever  is  more  constant  and  is  remittent  in  type,  while  the 
chills  disappear  although  profound  sweats  occur.  If  only  one  or  two 
abscesses  are  present  in  the  liver  this  organ  may  be  noticeably  en- 
larged. If  relief  is  not  soon  afforded,  sepsis  progresses,  the  patient 
may  become  delirious,  and  finally  death  from  exhaustion  ensues. 

The  question  of  operative  treatment  is  even  more  unsettled  than 
is  that  of  diagnosis.  It  is  impossible  to  drain  multiple  diffuse  ab- 
scesses of  the  liver.  One  or  two  larger-abscesses  may,  however, 
be  evacuated  and  recovery  ensue. 

At  times  a  peri-appendicular  abscess  may  burrow  upward 
behind  the  liver,  either  through  or  posterior  to  the  diaphragm,  and 
may  finally  rupture  into  the  lung,  the  pus  being  expectorated. 
The  following  is  an  illustrative  case: 

R.  S.,  a  male,  aged  nineteen  years,  was  admitted  to  the  German  Hospital 
on  August  25,  1895,  and  the  following  history  was  elicited:  He  had  always 
enjoyed  good  health  until  three  days  prior  to  admission,  when,  after  a  hearty 


342  Appendicitis 

meal,  he  commenced  to  complain  of  pain  in  the  epigastric  region.  This  was 
attended  by  vomiting,  which  afforded  no  relief.  The  pain  increased  in  severity 
and  became  localized  in  the  right  iliac  fossa,  which  was  markedly  tender  on 
pressure.  The  vomiting  finally  ceased,  but  nausea  persisted.  The  patient 
considered  himself  afflicted  with  an  ordinary  attack  of  intestinal  colic,  and  did 
not  summon  medical  aid  until  the  pain  had  become  unbearable.  He  was  sent 
immediately  to  the  hospital,  where,  upon  admission,  his  temperature  was  found 
to  be  102°  F.;  his  pulse-rate  94;  his  abdomen  slightly  distended  and  rigid, 
especially  upon  the  right  side,  where  tenderness  was  most  marked.  He  com- 
plained of  general  abdominal  pain. 

A  diagnosis  of  appendicular  abscess  was  made. 

Ice-bags  were  applied  to  the  abdomen  and  saline  purgatives  were  adminis- 
tered. Some  abatement  of  the  pain  and  tenderness  resulted.  Although  opera- 
tion was  strongly  advised,  it  was  absolutely  refused  by  the  boy's  parents.  At 
this  time  his  temperature  ranged  from  99°  to  99.8°  F.;  his  pulse-rate  from  84 
to  100.  He  was,  however,  fairly  comfortable,  despite  occasional  nausea  and 
vomiting  and  the  continuance  of  abdominal  tenderness.  He  remained  in  this 
condition  until  the  fourth  day  after  admission  (the  seventh  day  of  the  attack), 
when  he  suddenly  grew  worse,  his  temperature  rising  to  104°  F.  and  his  pulse- 
rate  to  120  a  minute.  He  vomited  continuously,  became  dyspnoeic,  and  expec- 
torated large  quantities  of  foetid,  muco-purulent  matter,  tinged  with  blood. 
Examination  of  this  revealed  no  tubercle  bacilli.  The  patient  became  exhausted 
and  died  nine  days  after  admission  to  the  hospital. 

At  necropsy  a  perforated  appendix,  pointing  north,  and  lying  just  below 
the  diaphragm,  was  found.  The  abscess  surrounding  the  appendix  had 
perforated  through  the  diaphragm  into  the  lung,  which  revealed  some  gangren- 
ous areas.  The  expectorated  matter  was  evidently  some  of  the  contents  of 
the  peri-appendicular  abscess. 

In  addition  to  this  case  I  have  encountered  several  other  cases 
in  which  the  pus  from  a  peri-appendicular  abscess  was  evacuated 
through  the  mouth.  Similar  cases  have  also  been  recorded  by 
other  surgeons. 

Subdiaphragmatic  abscess  is  a  not  infrequent  complication  of 
appendicitis.  It  is,  whether  developing  before  or  after  operation, 
to  be  considered  rather  as  a  complication  of  the  disease  than  as  a 
sequel  or  post-operative  complication.  It  occurred  twenty  times  in 
2400  cases,  and  of  these  four  recovered  and  sixteen  died.  Many 
of  these  instances  were  discovered  only  at  necropsy. 

Barnard  has  most  thoroughly  studied  the  subject  of  subdia- 
phragmatic abscess  and  found  appendicitis  responsible  in  twelve  of 
seventy-six  cases.  In  my  own  experience  the  percentage  has  even 
been  higher.     I  consider  subdiaphragmatic  abscess  one  of  the  most 


Complications  and  Sequels  343 

frequently   overlooked    of    all    the    complications   of    appendicitis. 
Barnard  states  that  appendicitis  may  infect  the  subdiaphragma- 
tic fossa  in  four  ways: 

1.  As  a  part  of  an  acute  general  peritonitis,  but  these  cases 
generally  are  not  classed  as  purely  subdiaphragmatic  abscess  and 
are  not  included  in  the  author's  statistics. 

2.  By  a  more  or  less  slow  and  direct  extension  up  the  lumbar 
peritoneal  fossa  from  the  pelvis. 

3.  Through  the  medium  of  the  portal  vein,  as  a  part  of  phlebitis. 

4.  By  lymphatic  extension  (a)  up  the  right  retro-peritoneal 
cellular  tissue,  or  (b)  up  the  lymphatics  around  the  deep  epigastric 
artery  to  the  falciform  ligament. 

The  symptoms  of  subdiaphragmatic  abscess  are  not  so  definite 
that  diagnosis  is  always  easy.  If,  however,  we  bear  in  mind  that 
it  is  found  as  a  result  of  appendicitis  practically  always  in  the  right 
side  of  the  abdomen  its  recognition  may  not  be  so  difficult.  More- 
over, in  several  cases  under  my  observation  it  has  occurred  weeks 
or  even  months  after  the  primary  operation  and  has  been  found  as 
a  complication  of  comparatively  mild  cases  of  appendicitis.  In 
general  we  may  say  that  subdiaphragmatic  abscess  gives  the  signs 
of  continued  infection  just  as  does  any  other  secondary  abscess 
after  an  operation  for  appendicitis.  In  addition  we  may  have 
tenderness  and  dullness  in  the  right  upper  abdominal  quadrant 
or  the  loin  space,  and  last  and  most  important  the  signs  of  pleural 
involvement  at  the  base  of  the  lung.  If  subdiaphragmatic  abscess 
is  suspected  needling  is  often  of  value  in  demonstrating  the  presence 
of  pus. 

The  treatment  consists  in  the  prompt  evacuation  of  the  abscess. 
This  may  be  approached  in  three  ways: 

1.  The  transpleural  route. 

2.  The  subpleural. 

3.  The  abdominal — median  epigastric  or  lumbar  as  indicated. 
The  prognosis  in  subdiaphragmatic  abscess  must  be  guarded. 

With  earlier  recognition  and  treatment  our  results  would  be  vastly 
improved. 

Purulent  pleurisy  or  empyema  is  usually  the  result  of  the  ex- 
tension of  a  subdiaphragmatic  abscess.  It  may  be  accompanied  by 
abscess  or  gangrene  of  the  lung.     I  have  seen  the  case  of  a  young  man 


344  Appendicitis 

who  suffered  an  attack  of  acute  appendicitis,  from  which  he  appar- 
ently recovered  without  an  operation.  Later  his  right  chest  filled  with 
fluid,  which  aspiration  proved  to  be  pus,  the  sequence  of  events  and 
the  character  of  the  pus  indicated  that  it  was  probably  the  con- 
sequences of  a  subdiaphragmatic  abscess.  A  rib  was  resected  and  he 
improved.  Still  later  the  sigmoid  flexure  was  perforated  and  a 
pelvic  abscess  evacuated  itself  through   the  rectum. 

Pneumonia  must  always  be  reckoned  with  as  a  possible  post- 
operative complication.  In  a  series  of  2400  cases  of  acute  appen- 
dicitis there  were  25  cases  of  post-operative  pneumonia  (i  per  cent.). 
Of  these,  16  recovered  and  9  died.  True  lobar  pneumonia  is  rarely 
seen  after  operation,  though  it  occasionally  occurs  particularly  when 
operation  must  be  done  in  the  presence  of  an  acute  "cold"  of  the 
upper  respiratory  passages.  For  this  reason  I  always  defer  operation 
when  the  patient  is  suffering  with  a  cold,  unless  the  condition  is 
urgent.  Pulmonary  infections  after  operation  are  almost  invariably 
of  the  broncho-pneumonic  type  and  are  caused  by  minute  septic 
emboli  obtaining  lodgment  in  the  lung  capillaries.  The  bases  of 
the  lungs  which  are  so  often  the  seat  of  hypostatic  congestion  and 
atelectasis  after  long  or  trying  operations  or  after  enforced  dorsal 
decubitus  are  the  most  frequent  sites  of  the  infection.  In  extreme 
cases  an  entire  lobe  or  lobes  may  be  involved  by  confluence.  A 
painful  pleurisy  may  complicate  the  situation..  These  cases  often 
run  a  sluggish  course  without  alarming  symptoms.  At.  other  times 
extreme  toxaemia  is  present  which  may  end  fatally.  The  treatment 
is  that  of  pneumonia  in  general.  If  possible  the  patient  should  be 
kept  in  the  open  air.  Support,  sedatives  or  stimulation  as  needed 
sum  up  the  indications.     Pulmonary  embolism  rarely  occurs. 

Pyaemia  may  follow  suppurative  appendicitis  and  its  localization 
may  be  legion.  Endocarditis,  arthritis,  abscesses  of  the  liver, 
spleen,  brain,  etc.,  have  been  observed  as  a  consequence.  Acute 
nephritis  of  severe  type  may  occur. 

Inflammation  of  the  parotid  gland  is  another  of  these  manifes- 
tations which  is  sometimes  encountered.  I  have  seen  one  case  of 
bilateral  suppurative  parotitis  in  a  case  of  extra-peritoneal  appen- 
diceal abscess.  D.  F.  Jones  has  recorded  a  remarkable  case  in  which 
a  girl  of  nineteen  years  developed  double  parotitis  (non-suppurative) 
three  times  as  a  complication  of  as  many  attacks  of  appendicitis.     He 


Complications  and  Sequels  345 

quotes  Stephen  Paget,  who  found  that  of  loi  cases  of  parotitis 
the  records  of  which  he  examined,  18  only  were  due  to  disease  or 
injury  of  the  alimentary  canal,  23  to  that  of  the  abdominal  wall, 
10  to  that  of  the  genito-urinary  tract,  and  50  to  disease  or  temporary 
derangement  of  the  generative  organs.  I  have  encountered  several 
examples  of  parotitis  occurring  usually  about  three  days  after  opera- 
tion and  subsiding  without  suppuration,  but  have  considered  them 
more  in  the  light  of  accidental  infections  of  the  salivary  glands  in- 
dependent of  the  abdominal  lesion.  I  have  also  seen  the  parotid 
gland  suppurate,  necessitating  incision.  In  one  case  the  abscess 
evacuated  itself  spontaneously  into  the  mouth. 

The  dryness  of  the  mouth,  the  stagnation  of  the  parotid  secretion 
during  anaesthesia  and  later  by  reason  of  the  enforced  liquid  diet, 
together  with  possible  injury  to  the  exit  of  Steno's  duct  by  the  fingers 
of  the  ansesthetist,  are  all  favoring  factors  in  the  production  of  paroti- 
tis should  a  mouth  infection  ascend  the  duct. 

Abscess  of  the  abdominal  wall  consequent  upon  an  appendi- 
citis may  occur  in  rare  instances.  The  following  is  an  illustrative 
case: 

A  boy,  aged  thirteen  years,  with  a  history  of  three  attacks  of  appendicitis, 
was  referred  to  me  by  my  friend,  Dr.  P.  F.  Moylan.  During  his  last  attack 
the  boy  had  been  attended  by  Dr.  Moylan,  who  said  to  me  that  at  the  time 
of  his  first  visit  there  was  a  general  peritonitis,  which  was  attended  by  so 
much  distention  that  he  was  unable  to  make  out  by  examination  the  cause 
of  the  peritonitis.     There  was  apparent  recovery  after  this  attack. 

At  operation,  performed  by  making  an  incision  through  the  right  semi- 
lunar Hne,  a  cheesy  mass  situated  beneath  the  transversalis  muscle  was  dis- 
closed. The  peritoneum  beneath  this  collection  had  been  destroyed  and 
the  mass  was  limited  posteriorly  by  the  great  omentum.  The  cheesy  material 
was  curetted  away  and  the  cavity  was  antisepticized.  The  diseased  portion 
of  the  omentum  was  ligated  from  the  remaining  healthy  portion  and  was 
excised.  The  caecum  contained  two  perforations,  which  were  exposed  after 
the  removal  of  the  diseased  and  adherent  omentum.  The  appendix  was  post- 
caecal  and  embedded  in  a  mass  of  coagulated  lymph,  and  was  perforated  at 
its  base.  The  pelvis  contained  a  collection  of  pus,  which  was  limited  by 
adherent  coils  of  intestine. 

The  patient  recovered. 

Among  the  important  complications  of  appendicitis  are  various 
lesions  of  the  gastro-intestinal  tract. 


346  Appendicitis 

Obstruction  of  the  intestine  consequent  upon  contraction  of 
peritoneal  adhesions  is  one  of  the  most  common.  Intestinal  obstruc- 
tion is  more  frequently  encountered  after  operations  in  pus  cases, 
but  may  occur  in  chronic  cases,  and  in  some  instances  the  first 
symptoms  complained  of  may  be  those  of  intestinal  obstruction, 
more  or  less  complete.  These  peritoneal  bands  should  be  sought 
for,  and,  if  detected,  should  be  di\ided  at  every  operation  for  appen- 
dicitis. Even  when  actual  strangulation  does  not  exist,  the  obstruc- 
tion may  be  sufficient  to  cause  the  most  distressing  gastro-intestinal 
symptoms,  such  as  obstinate  constipation,  flatulency  and  colic. 
The  obstruction  may  be  due  to  generalized  adhesions,  or  to  a  single 
band  beneath  which  a  knuckle  of  gut  becomes  constricted.  In  the 
former  case  there  is  not  often  strangulation  of  the  bowel,  but  the 
gastro-intestinal  symptoms  above  mentioned  are  almost  invariably 
present.  But  if  the  appendix  itself,  or  some  distinct  peritoneal 
band,  extends  from  one  portion  of  the  abdomen  to  another,  no 
symptoms  of  any  consequence  may  arise  until  suddenly  acute  intes- 
tinal obstruction  occurs  from  the  strangulation  of  the  bowel  beneath 
this  band.  I  have  seen  a  case  in  which  a  peritoneal  band  the  result 
of  chronic  appendicitis  was  stretched  between  the  appendix  and  a 
Meckel's  diverticulum.  Obstruction  resulted  "from  a  coil  of  intestine 
becoming  engaged  beneath  this  band.  A  case  in  which  the  appendix 
became  adherent  to  the  sigmoid  flexure,  forming  a  bi-mucous  fistula, 
is  referred  to  at  page  21.  I  have  seen  intestinal  obstruction  follow 
the  contraction  of  the  walls  of  an  appendiceal  abscess  in  which  the 
wall  of  the  abscess  cavity  was   made  up  largely  of  small  intestine. 

Among  the  most  intractable  accompaniments  of  appendicitis 
is  mucous  or  membranous  colitis.  In  some  cases  the  obtruding 
symptoms  are  purely  those  of  the  colitis,  and  the  diseased  condition 
of  the  appendix  may  be  for  a  long  time  unsuspected.  At  times  there 
are  also  manifestations  of  indigestion,  and  at  other  times  the  most 
aggravated  neurasthenia.  Indeed,  it  is  quite  certain  that  a  not  in- 
considerable percentage  of  neurasthenics  suffer  from  chronic  appen- 
dicitis; but  as  mentioned  in  the  chapter  on  Chronic  Appendicitis, 
it  does  not  always  happen,  as  in  the  following  case,  that  removal  of 
the  appendix  effects  a  cure  of  the  neurasthenia  as  well  as  of  the 
gastro-intestinal  symptoms : 


Complications  and  Sequels  347 

Miss  P.,  aged  forty-four  years,  was  referred  to  me  with  the  following 
history:  For  the  past  three  years  she  had  suffered  from  a  mucous  diarrhoea, 
which  had  been  attributed  by  various  physicians  to  enterocolitis,  dysentery, 
etc.,  and  had  been  treated  by  the  most  diverse  methods,  from  bismuth  by 
the  mouth  to  quinine  and  nitrate  of  silver  by  the  rectum. 

Upon  admission  to  the  German  Hospital  she  was  markedly  neurasthenic 
and  much  emaciated.  Her  bowel  movements  averaged  from  four  to  eight 
daily.  They  contained  mucus,  shreds  of  mucous  membrane,  and  blood. 
Upon  careful  examination  the  appendix  was  found  enlarged  and  was  painful 
on  pressure;  there  was  no  rigidity  of  the  abdominal  wall.  She  gladly  con- 
sented to  operation,  in  the  hope  of  obtaining  relief,  and  the  appendix,  when 
removed,  was  found  to  present  typically  the  lesions  of  catarrhal  inflammation. 
Recovery  from  the  operation  was  uninterrupted.  The  bloody  and  mucous 
stools,  the  neurasthenia,  and  the  emaciation,  however,  did  not  markedly 
improve  for  over  three  months  after  the  operation,  when  her  symptoms  rapidly 
abated.  She  gained  flesh,  and  within  one  year  she  considered  herself  entirely 
cured.  The  digestive  functions  were  performed  normally,  the  neurasthenia 
had  disappeared,  and  she  had  increased  in  weight  over  twenty  pounds. 

The  removal  of  the  diseased  appendix,  which  may  or  may  not 
be  the  primary  cause  of  a  train  of  symptoms  like  those  just  narrated, 
is  of  utility  only  in  that  it  removes  a  portion,  even  if  it  be  considered 
the  most  important  portion,  of  the  cause  of  the  symptoms.  The 
other  morbid  conditions  present  will  then  require  treatment,  and  it 
is  often  months  or  years  before  decided  improvement  is  manifest. 
Indeed  I  have  now  seen  so  many  cases  where  the  removal  of  a  chron- 
ically diseased  appendix — one  which  has  never  produced  acute 
symptoms — seemed  to  have  absolutely  no  effect  on  the  neurasthenic 
and  gastro-intestinal  symptoms,  that  I  feel  very  doubtful  whether 
such  an  appendix  may  not  be  considered  as  much  the  result  as  the 
cause  of  the  disease. 

Hernia  of  some  form  or  variety  may  complicate  an  attack  of 
appendicitis,  and  if  the  hernia  be  strangulated,  or  even  if  it  be  only 
irreducible  or  inflamed,  or  if  strangulation  be  suspected,  the  symp- 
toms of  the  appendicular  inflammation  may  be  entirely  obscured, 
as  is  illustrated  by  the  following  case: 

Mrs.  X.,  aged  forty-two  years,  was  admitted  to  the  German  Hospital  and 
the  following  history  -w^as  elicited:  Two  days  prior  to  admission  she  had  been 
attacked  with  general  abdominal  pain,  which  was  associated  with  vomiting 
and  marked  constipation.  The  attending  physician  detected  a  mass  in  the 
right  inguinal  canal  which  the  patient  stated  was  an  old  hernia.     The  mass 


348  Appendicitis 

was  tender  on  pressure  and  was  irreducible  by  taxis,  even  under  anaesthesia. 
The  patient  steadily  grew  worse,  and  the  following  morning  she  was  again 
etherized  and  another  futile  attempt  was  made  to  reduce  the  mass.  She 
was  then  removed  to  the  hospital,  where  I  saw  her.  The  mass  was  tender 
and  was  evidently  inflamed;  the  abdomen  was  distended  and  the  bowels  were 
absolutely  constipated;  vomiting  occurred  frequently.  Incision  over  the  tumor 
showed  that  it  was  the  sac  of  an  old  hernia  which  was  not  the  seat  of  inflamma- 
tion. By  extending  the  original  wound  the  peritoneal  cavity  was  opened,  and 
a  general  purulent  peritonitis  was  disclosed.  The  appendix  which  was  exten- 
sively diseased  was  removed.  The  peritoneal  cavity  was  thoroughly  irrigated, 
drainage  was  introduced,  and  the  wound  was  closed.  The  patient  did  not  rally, 
but  died  eighteen  hours  after  the  operation. 

The  original  site  of  inflammation  was  undoubtedly  the  appendix,  but  the 
hernia  and  the  mass  to  which  it  gave  rise  in  the  right  inguinal  canal  had  misled 
both  the  attending  physician  and  myself. 

Not  only  may  appendicitis  be  mistaken  for  a  strangulated  hernia 
and  vice  versa,  but  the  appendix  may  be  found  in  the  sac  of  the 
hernia,  of  either  the  inguinal  or  femoral  variety.  It  has  been 
observed  in  left-sided  hernias  as  well  as  in  those  on  the  right,  being 
probably  carried  into  these  abnormal  positions  by  the  ileum,  which 
is  the  part  of  the  intestinal  tract  most  frequently  found  in  hernial 
sacs.  The  appendix  may  remain  in  the  sac  for  years,  unattended 
by  symptoms;  it  may  be  found,  uninflamed,  in  the  midst  of  strangu- 
lated bowel,  at  a  herniotomy;  it  may  become  inflamed,  and  suppura- 
tion may  occur,  in  the  hernial  sac,  without  there  being  any  strangu- 
lation, yet  producing  symptoms  nearly  typical  of  strangulated  hernia; 
or  it  may  be  detected  only  by  accident  at  necropsy,  or  at  operation 
for  the  radical  cure  of  the  hernia. 

Tuberculosis,  either  latent  or  active,  is  a  very  grave  complica- 
tion of  appendicitis.  I  have  frequently  been  impressed  by  the  fact 
that  in  many  cases  that  do  badly  there  is  a  tuberculous  family 
history,  even  if  no  demonstrable  tuberculous  lesions  exist  in  the 
patient.  The  underlying  condition  may  thus  be  not  only  one  of 
diminished  power  of  resistance  to  the  influence  of  agents  provocative 
of  acute  inflammation,  but  also,  in  some  instances  at  least  the  con- 
sequence of  dormant  tubercle  bacilli  being  roused  into  activity  by 
the  appendicular  disease.  Be  this  as  it  may,  the  fact  is  certain  that 
protracted  convalescence,  the  development  of  multiple  abscesses, 
or  of  a  faecal  fistula,  and  other  debilitating  results,  are  to  be  greatly 
feared  in  the  tuberculous  subject.     Indeed  it  is  questionable,   I  . 


Complications  and  Sequels  349 

think,  whether  it  is  always  wise  to  remove  an  appendix  from  an 
undoubtedly  tuberculous  subject,  except  for  acute  disease.  Where 
the  disease  is  chronic,  or  at  most  subacute,  I  think  the  surgeon  will 
do  well  to  palliate,  as  any  operation  on  such  subjects  is  liable  to 
rouse  into  activity  dormant  tuberculous  processes;  and  the  exchange 
of  a  semi-quiescent  appendix  for  a  persistent  fsecal  fistula  or  active 
tuberculosis  elsewhere  will  be  most  unsatisfactory  to  all  concerned. 
I  have  seen  a  number  of  such  results  which  were  unavoidable,  as 
operation  was  undertaken  for  the  evacuation  of  appendiceal  ab- 
scesses; but  where  an  operation  is  not  imperative,  temporizing  will 
as  a  rule  be  more  to  the  interest  of  the  patient. 

Finally,  extremely  important  complications  and  sequels  of 
appendicitis  are  certain  diseases  of  the  female  genitalia.  Ap- 
pendicitis of  every  variety  has  been  found  associated  with  almost 
every  pathological  condition  of  the  pelvic  organs.  The  sequence 
of  events  varies  in  different  cases;  at  times  the  lesions  commence 
in  the  appendix  and  subsequently  involve  the  genitalia;  at  other 
times  the  inflammatory  phenomena  are  inaugurated  in  some  portion 
of  the  genitalia  and  later  implicate  the  appendix.  From  rather 
extensive  observation  it  has  seemed  to  me  that  the  former  is  not  at 
all  uncommon,  (i)  because  widespread  pelvic  lesions  are  not  likely  to 
be  encountered  in  young  women  and  girls  in  whom  no  history  or 
sign  of  external  infection  can  be  detected;  (2)  because  of  the  exces- 
sive virulence  of  appendicular  pus  and  the  especial  faculty  it  pos- 
sesses of  inaugurating  purulent  processes  in  other  portions  of  the 
body;  (3)  because  the  right  tube  may  be  markedly  involved  and  ad- 
herent to  the  appendix  while  the  left  tube  is  normal,  and  (4)  because 
the  initial  symptoms  point  rather  to  disease  of  the  appendix  than  to 
disease  of  the  genitalia.  Although  the  diseased  processes  in  indi- 
vidual cases  may  commence  in  the  genitalia,  the  manifestations  of 
appendicitis  may  be  so  prominent  that  the  symptoms  of  uterine, 
tubal,  or  ovarian  disease  are  obscured,  and  are  revealed  only  by 
operation  or  necropsy. 

When  a  peri-appendicular  abscess  occupies  the  pelvis  it  usually 
results  from  an  ulcerative  or  gangrenous  inflammation  of  an  appen- 
dix that  points  due  south  or  southeast.  In  these  cases  the  distal 
extremity  only  of  the  organ  may  be  affected,  but  it  is  usually  in  close 
relationship  with  one  of  the  pelvic  organs.     The  pain  in  these  cases 


350  Appendicitis 

is  usually  left  sided,  and  the  abscess  formed  is  of  moderate  size  only. 
For  these  reasons  there  is  great  liability  of  confounding  the  condi- 
tions with  disease  of  the  pelvic  organs,  and  errors  in  diagnosis  are 
rendered  still  more  likely  because  of  the  rapid  formation  of  firm 
adhesions  that  limit  the  abscess  to  the  immediate  vicinity  of  the  sig- 
moid flexure,  the  rectum  or  the  bladder.  The  bladder  and  sigmoid 
flexure  may  be  perforated.  Two  cases  of  this  character  have  already 
been  referred  to. 

Special  emphasis  must  therefore  be  directed  to  the  clinical  im- 
portance of  these  pelvic  lesions — conditions  in  which  both  the  tubes 
and  ovaries,  together  with  the  appendix,  are  involved  in  phlegmon- 
ous inflammation.  Surgically  they  may  present  difflculties  that  are 
insurmountable.  The  various  organs  are  covered  by  great  masses 
of  fibrinous  or  fibrino-purulent  exudate  in  which  one  or  more 
abscesses  may  be  encountered.  There  are  also  found  dense  adhesions 
that  have  so  devitalized  the  tissues  that  the  slightest  traction  is  likely 
to  lead  to  rupture  of  the  bladder  or  the  intestine. 

These  conditions  not  only  possess  a  present  danger,  but  also  a 
most  serious  remote  danger,  in  that  they  exhibit  a  most  persistent 
tendency  to  recur,  a  tendency  which  it  is  sometimes  beyond  the  power 
of  human  skill  to  overcome.  As  already  mentioned,  intestinal  ob- 
struction and  strangulation  may  ensue.  In  addition,  the  omentum 
frequently  becomes  attached  to  the  parietal  peritoneum,  and,  by  its 
efforts  to  free  itself,  as  well  as  by  certain  of  the  patient's  movements, 
such  as  coughing,  sneezing,  deep  inspirations,  etc.,  intense  pain  may 
be  provoked.  Indeed,  in  some  cases  even  slight  adhesions  are  suf- 
ficient to  constitute  a  source  of  considerable  trouble  and  complaint. 

Pregnancy  also  may  complicate  appendicitis,  and  vice  versa, 
and  is  always  a  cause  of  anxiety.  If  appendicitis  occurs  during  the 
early  stages  of  gestation,  abortion  frequently  results.  In  any  case 
a  pregnant  woman  who  is  attacked  by  acute  appendicitis  should  be 
operated  upon  as  soon  as  practicable  after  the  onset  of  the  initial 
pain.  The  removal  of  a  diseased  appendix  during  pregnancy  is 
attended  by  few  if  any  risks  to  either  mother  or  foetus,  apart  from 
those  dangers  that  may  attend  any  operation.  The  usual  risks,  on 
the  other  hand,  that  accompany  the  non-removal  of  an  inflamed  ap- 
pendix, in  every  case,  are  much  increased  by  the  pregnant  state,  and 
the  evil  consequences  of  a  subsequent  attack  of  appendicitis,  with 


Complications  and  Sequels 


351 


perhaps  perforation  and  gangrene,  are  correspondingly  augmented. 
A  recurrent  attack  with  pus  formation  may  occur  at  a  later  stage  of 
the  same  pregnancy  when  the  dangers  of  operation  and  miscarriage 
may  be  considerably  greater  that  in  the  early  stages.  I  have  seen 
a  number  of  cases  of  appendicitis  in  pregnant  women  in  whom,  as 
a  consequence  of  delay  in  operation,  the  right  uterine  adnexa  have 
become  infected,  and  most  serious  conditions — in  some  instances 
death — have  ensued.  The  earlier  the  operation,  the  less  the  likeli- 
hood of  infection  of  the  right  tube  and  ovary,  and  the  less  likely, 
therefore,  the  development  of  serious  complications.  The  wisdom 
of  early  operations  is  especially  evident  from  the  fact  that  I  have 
never  had  abortion  to  occur  in  pregnant  women  upon  whom  I  have 
operated  for  acute  appendicitis  unless  the  right  uterine  appendages 
were  involved  in  the  disease  and  seldom  then.  Appendicitis  also  may 
complicate  parturition  and  the  puerperium,  and  in  either  condition  is 
of  serious  moment.  The  establishment  of  a  differential  diagnosis 
between  ante-partum  or  post-partum  sepsis  and  appendicular  sepsis 
will  often  tax  the  resources  of  the  most  erudite  and  experienced. 
The  havoc  which  may  result  from  suppurative  pelvic  appendicitis 
in  a  young  girl  is  appalling. 

POST-OPERATIVE  COMPLICATIONS  OF  ACUTE  APPENDICITIS. 


German 
Hospital 


Children's 
Hospital 


Total 


Number  of  cases  reviewed . 
Number  of  complications . . 

Number  of  deaths 

Number  of  recoveries 


1997 
236 

77 
159 


403 
90 

23 
67 


2400 
326 
100 
226 


Acute  Dilatation  of  Heart 

Cases 4 

Death 4 

Abscess,  Secondary 

Cases 47 

Recover}^ 34 

Death 13 


Abscess,  Sub-phrenic 

Cases 20 

Recovery 4 

Death 16 

Anuria 

Cases I 

Recovery i 


352 


Appendicitis 


Abscess,  Peri-splenic 

Cases 

Death 


Apoplexy 

Cases I 

Recovery i 

Bronchitis 

Cases 6 

Recovery 6 

Cerebral  Embolism 

Cases 2 

Recovery i 

Death i 

Cystitis 

Cases 2 

Recovery 2 

Delirium  Tremens 

Cases 7 

Recovery 4 

Death 3 

Diarrhoea 

Cases 2 

Recovery i 

Death i 

Diphtheria 

Cases 2 

Recovery 2 

Edema  of  Ltings 

Cases 4 

Death 4 

Endocarditis 

Cases 2 

Recovery 2 


Epididymitis  and  Orchitis 

Cases 

Recovery 


Enteric  Fever 
Cases. . . . 
Recovery . 

Erysipelas 
Cases .... 
Recovery . 


Evisceration  from  Crying 

Cases 2 

Recover\- 2 

Fa?cal  Fistula 

Cases 42 

Recover}- 36 

Death 6 

Closed  spontaneously 28 

Closed  by  operation 4 

Persisted 4 

Fistula  in  Ano 

Cases I 

Recovery i 

Furunculosis 

Cases I 

Recovery i 


Gangrene  of  spleen i 

Gangrene  of  ileum i 

Death 2 

Hjemorrhage 

Cases I 

Death i 


Haemorrhage,  Secondary 

Cases 2 

Recoverj' i 

Death i 

Hernia 

Cases 3 

Recoverj' 3 

Hiccough 

Cases I 

Recovery i 

(coughed  wound  open) 

Intestinal  Obstruction 

Cases S3 

Recover}- 23 

Death 10 

Insanity,  Post-operative 

Cases I 

Recovery i 

Influenza 

Cases I 

Recovery i 


Complications  and  Sequels 


353 


Ischio-rectal  Abscess 

Cases 

Recovery 


Measles 

Cases 2 

Recovery 2 

Melaena 

Cases 2 

Recovery 2 


Necrosis  of  the  Bowel 

Cases 

Recovery 

Death 


19 


Nephritis 

Cases 3 

Recovery 3 

Otitis  Media 

Cases I 

Recovery i^ 

Parotitis 

Cases 3 

Recovery 3 

Peri-rectal  Abscess 

Cases I 

Recovery i 

Pertussis 

Cases I 

Recovery i 


Phlebitis 

Cases .... 
Recovery . 

Pleurisy 

Cases .... 
Recovery . 


Pneumonia 

Cases 25 

Recovery 16 

Death 9 

(includes  one  of  tuberculosis) 

23 


Pulmonary  Embolism 

Cases 5 

Recovery i 

Death 4 

Relaxed  Sphincter 

Cases I 

Recovery i 

Retention  of  Urine 

Cases 3 

Recovery 3 

Rheumatism 

Cases I 

Recovery i 


Salpingitis 

Cases 

Recovery 

(Operation  2nd) 


Scarlatina i 

Recovery i 

Scarlet  Fever 

Cases 1 

Recovery i 


Sinus  Persistent 

Cases 

Recovery . . . 


Shock 

Cases I 

Death i 

Sub-phrenic,  Sub-diaphragmatic 
Abscesses 

Cases 20 

Recovery 4 

Death 16 

Tonsillitis 

Cases 3 

Recovery 3 

Ulcer  decubitus 

Cases I 

Recovery i 

Uraemia 

Cases 2 

Death 2 


APPENDIX 


THE  MEDICAL  TREATMENT  OF  APPENDICITIS 

Medical  treatment  should  not  be  used  in  appendicitis  except 
as  directed  below. 

Under  ideal  conditions  the  role  of  the  physician  in  acute  appen- 
dicitis is  to  make  the  diagnosis  and  to  impart  his  knowledge  of 
the  condition  to  the  patient  or  his  family  with  the  strongest  recom- 
mendation that  the  surgeon  be  called  and  the  case  placed  in  his 
charge  as  expeditiously  as  possible.  It  must  be  recognized,  how- 
ever, that  under  the  many  and  varied  conditions  of  practice  in 
which  so  frequent  a  disease  may  be  encountered,  it  is  not  always 
possible  to  meet  the  requirements  of  ideal  treatment.  Therefore, 
a  brief  consideration  of  this  important  subject  from  the  standpoint 
of  the  general  practitioner  may  not  be  out  of  place. 

It  must  be  thoroughly  understood  that  any  deviation  from  the 
principle  of  immediate  operation  can  be  justified  anly  by  circum- 
stances which  are  beyond  the  control  of  the  physician.  It  occasion- 
ally happens  that  the  prejudice  against  surgery  on  the  part  of  the 
patient  or  his  responsible  relatives  will  cause  him  to  decline  to 
act  upon  the  recommendation  of  the  physician.  In  the  present 
state  of  education  of  the  laity  in  respect  to  this  disease  it  is  rare 
to  meet  such  a  refusal.  Of  late  years,  indeed,  it  has  been  my 
experience  to  find  more  often  the  reverse  condition,  namely,  the 
patient  insisting  upon  operation  in  the  face  of  the  too  optimistic 
physician  who  is  willing  to  temporize  with  medical  measures. 
Occasionally  there  may  exist  relative  or  absolute  contraindications 
to  operation  which  make  its  performance  at  the  time,  or  at  any 
time,  inadvisable.  As  absolute  contraindications  may  be  instanced 
the  presence  of  broken  cardiac  compensation,  of  pneumonia  or  any 
general  disorder  which  is  acutely  threatening  to  life.  Relative 
contraindications  are  to  be  found  chiefly  in  the  presence  of  chronic 
disease  of  the  heart,  lungs  or  kidneys,  or  the  less  severe  general 
disorders,  which,  while  not  necessarily  immediately  threatening  to 

355 


35^  Appendix 

life,  are  yet  of  such  a  character  as  to  be  unfavorably  influenced 
by  the  performance  of  an  operation. 

Surgical  advice  is  to  be  sought  in  these  cases  just  as  in 
those  where  operation  is  clearly  indicated,  since  the  surgeon  is 
necessarily  better  informed  as  to  the  relation  of  general  disease  to 
operation. 

There  are  some  localities  where  a  surgeon  is  not  available  and 
many  where  more  or  less  delay  is  unavoidable  before  operation 
can  be  performed.  "It  must  be  insisted  that  the  abdomen  should 
not  be  opened  by  the  family  physician,  unless  he  is  a  skilled  surgeon. 
In  these  days  of  rapid  transportation  a  surgeon  can  soon  reach 
the  patient.  An  operation  for  appendicitis  by  an  unskilled  man 
would  have  more  risks  to  the  patient  than  delay"  (Fussell).  In 
the  majority  of  cases  the  patient  looks  to  the  physician  for  some 
sort  of  treatment  prior  to  the  arrival  of  the  surgeon,  and  not  infre- 
quently in  cases  where  the  diagnosis  is  not  at  once  clear,  the  phy- 
sician is  obliged  to  institute  treatment  which  will  at  least  satisfy 
the  mind  of  the  patient  during  the  period  of  doubt  as  to  the  true 
diagnosis.  The  necessity  for  beginning  treatment  in  the  very 
early  stages  of  the  disease  before  a  diagnosis  is  made  between 
appendicitis  and  simple  colic  or  gastro-enteritis  or  one  of  the  many 
other  painful  abdominal  affections  has  been  responsible  for  many 
fatalities.  Certainly  every  effort  should  be  made  to  differentiate 
these  conditions,  which  may  usually  be  done  by  observing  carefully 
the  points  already  mentioned  in  the  chapter  on  differential  diagnosis. 
Still,  occasional  cases  will  be  encountered  which  cannot  at  once  be 
correctly  diagnosticated.  A  certain  period  of  observation  becomes 
necessary  and  it  is  during  this  time  that  the  most  flagrant  errors 
are  committed  in  the  treatment  of  the  case  should  it  prove  to  be 
appendicitis.  The  physician  who  sees  many  minor  ailments  is 
rather  too  free  to  assume  that  the  doubtful  case  is  one  of  simple 
colic  and  indigestion  to  be  treated  by  a  purge  with  an  anodyne 
if  pain  is  prominent.  I  have  no  hesitation  in  saying  that  to  these 
two  factors,  purgatives  and  anodynes,  may  be  attributed  the  greater 
part  of  the  mortality  due  to  acute  appendicitis.  This  unenviable 
eminence  is  earned  by  anodynes  through  the  part  they  play  in 
obscuring  diagnosis,  allaying  the  alarm  of  patient  and  physician 
and  thus  delaying  operation,  delay  being  the  most  important  single 


Appendix  357 

cause  of  death  from  this  disease.  Purgatives  if  given  with  intention 
or  in  the  misguided  belief  that  the  condition  is  other  than  appen- 
dicitis hastens  inflammation,  suppuration  and  perforation  of  the 
appendix  itself  and  disseminates  peritonitis.  Therefore  the  prin- 
ciple may  be  laid  down  that  in  case  of  doubt  as  to  the  existence  of 
an  acute  surgical  condition  it  is  safer  to  institute  treatment  under 
the  presumption  that  the  surgical  condition  is  present,  since  much 
harm  may  be  done  by  ill-advised  medication  and  improper  handling 
of  the  early  stages  of  acute  surgical  disease  of  the  abdomen,  while 
delay  in  beginning  treatment  rarely  influences  the  outcome  of 
medical  conditions. 

The  most  important  points  to  be  observed  in  the  suspected 
presence  of  acute  appendicitis  are  negative  rather  than  positive 
and  consist  in  the  prohibition  of  everything  by  mouth,  including 
water,  and  especially  the  avoidance  of  all  purgative  medicine. 
Morphia  and  other  anodynes  should  be  avoided  until  the  diagnosis 
or  indications  for  treatment  become  clear.  When  peritonitis  is  sus- 
pected the  sitting  position  should  be  adopted  at  once.  Ice  bags  may 
be  placed  over  the  abdomen,  or  hot  applications  if  they  are  desired 
and  prove  to  be  more  comforting  to  the  patient.  A  small  simple 
enema  should  be  given,  following  which,  continuous  or  intermittent 
proctoclysis  should  be  begun.  By  this  treatment  the  diagnosis 
will  not  be  obscured  and  in  the  event  of  acute  appendicitis  even  if 
it  progresses  to  gangrene,  perforation,  or  spreading  peritonitis, 
the  patient  will  be  given  the  best  chance  for  recovery  either  with 
or  without  operation. 

When  the  diagnosis  of  acute  appendicitis  is  established,  if  a 
considerable  interval  must  elapse  before  operation  can  be  done 
the  measures  to  be  employed  may  be  summarized  as:  (i)  sitting 
posture;  (2)  prohibition  of  all  medicine,  food  or  drink  by  mouth; 
(3)  gastric  lavage,  particularly  if  a  meal  has  just  been  taken  or 
if  vomiting  is  a  feature;  (4)  ice  bags  on  the  abdomen;  (5)  proc- 
toclysis; (6)  avoidance  of  anodynes,  except  in  the  presence  of  severe 
pain  or  restlessness,  when  a  small  dose  of  morphia  is  permissible. 
These  measures  are  simple  applications  of  the  principles  of  anatomic 
and  physiologic  rest,  upon  which  the  entire  medical  treatment  o^f 
appendicitis  depends.  Their  rationale  has  already  been  suflSciently 
discussed    in  the  chapter  on  Surgical  Treatment.     In  the  minor 


358  Appendix 

attacks  or  exacerbations  of  the  disease  such  treatment  may  seem  un- 
duly rigid  and  severe,  yet  such  is  the  insidious  character  of  the  dis- 
ease that  it  is  best  to  follow  closely  the  plan  outlined,  since  this  is  in 
itself  not  only  harmless  but  actually  beneficial,  while  if  neglected 
the  consequences  in  a  percentage  of  cases  will  be  most  disastrous. 

A  patient  so  treated  will  be  brought  to  the  surgeon  in  the  best 
possible  condition  for  operative  treatment.  If  for  any  unavoidable 
reason  operation  cannot  be  done  the  same  measures  should  be 
carried  out  during  the  subsequent  course  of  the  disease  which 
commonly  eventuates  in  several  well-known  ways  which  cannot, 
however,  be  foretold  for  the  individual  patient.  Many  cases  will 
subside  and  recover  from  the  acute  attack,  bearing,  however,  as  a 
rule,  adhesions,  torsions,  angulations  or  cicatrices  of  the  appendix 
which  predispose  to  subsequent  attacks.  At  times  diffusing 
peritonitis  will  progress  to  general  involvement  producing  over- 
whelming toxaemia  and  death.  If  the  line  of  treatment  indicated 
be  carefully  followed  out,  general  peritonitis  will  rarely  result.  More 
often  the  process  will  be  arrested  and  the  inflammation  localized 
about  the  appendix  forming  a  periappendicular  abscess.  There  is 
no  medical  treatment  for  this  condition  and  while  in  an  occasional 
fortunate  case  such  an  abscess  may  rupture  into  the  bowel  or  through 
the  parietes  and  thus  discharge  itself,  this  is  an  exceedingly  rare 
occurrence  and  to  refuse  operation  in  such  a  condition  is  usually 
synonymous  with  suicide.  There  is  no  contraindication,  either 
relative  or  absolute,  that  should  deter  the  surgeon  from  the  attempt 
to  open  a  periappendicular  abscess. 

Ordinarily,  alimentation  is  not  a  factor  to  be  considered  during 
the  period  preliminary  to  operation.  If  that  period  be  unduly 
prolonged,  or  in  the  absence  of  operation,  rectal  feeding  may  be 
tried.  Alcohol  in  the  form  of  a  small  dose  of  brandy  or  whiskey 
given  with  the  saline  solution  by  bowel  is  absorbable  and  of  some 
value  as  a  food.  Dextrose  also  is  available  and  may  be  used  to 
replace  the  salt  in  making  the  solution  isotonic.  Predigested  beef 
juice  or  milk  are  also  of  some  service.  The  usual  complex,  flavored 
and  undigested  foods  given  by  rectum  are  useless  or  worse.  The 
taking  of  food  or  fluid  by  mouth  is  to  be  postponed  until  peritonitis, 
if  present,  has  subsided  and  peristalsis  is  resumed. 

In  the  cases  not  suitable  for  operation  drugs  may  be  employed 


Appendix  359 

during  the  course  of  the  disease  for  their  stimulant  or  sedative 
effect  as  symptomatically  required.  Extreme  pain  demands 
opium  carefully  administered,  care  being  taken  that  the  patient 
is  not  narcotized.  For  distention,  turpentine  stupes,  stimulant 
enemata,  the  insertion  of  the  rectal  tube,  asafoetida  suppositories, 
and  finally  eserin  and  strychnia  hypodermically  may  be  employed, 
though  the  paralytic  distention  due  to  sepsis  is  but  little  influenced 
by  any  of  these  measures,  while  mechanical  ileus  responds  not  at  all. 

In  conclusion  it  may  be  stated  that  the  only  legitimate  field 
for  the  so-called  Medical  Treatment  of  Acute  Appendicitis  is  as  a 
preliminary  to  operation  which  should  not  be  delayed  thereby; 
that  in  this  period  the  chances  of  recovery  are  much  affected  by  the 
measures  adopted  by  the  physician;  that  medical  treatment  of 
appendicitis  throughout  its  course  is  justifiable  only  by  rare  and 
special  conditions;  that  its  outcome  is  problematical  but  the  out- 
look may  be  improved  by  rational  therapy  conducted  along  the 
lines  of  anatomic  and  physiologic  rest. 

The  ideal  treatment  of  chronic  appendicitis,  just  as  in  the 
acute  form  of  the  disease,  is  operation.  Obviously,  however,  the 
necessity  for  haste  is  less  pressing.  Ample  time  may  be  given 
to  the  preparation  of  the  patient  for  operation.  The  mouth  and 
teeth  should  be  brought  into  good  condition.  The  diet  and  bowels 
should  be  carefully  regulated.  The  activity  of  the  skin  and  kid- 
neys should  be  assured.  Excesses  of  whatever  nature  should  be 
curtailed  and  in  short  every  hygienic  measure  should  be  employed 
in  order  that  the  health  and  the  resistance  of  the  patient  may  be 
at  the  highest  point  when  operation  is  performed. 

The  simple  removal  of  a  chronically  diseased  appendix  as  done 
by  an  experienced  surgeon  upon  a  patient  in  ordinarily  good  health 
is  an  operation  that  is  almost  devoid  of  mortality.  It  is  not  to 
be  compared  in  point  of  danger  to  the  harboring  of  a  diseased 
appendix,  which  we  know  in  a  large  percentage  of  cases  gives  rise 
sooner  or  later  to  an  acute  attack.  The  physician's  advice  to  the 
patient,  therefore,  should  be  based  upon  this  fact.  If  operation  is 
not  accepted  by  the  patient  it  should  be  with  the  full  knowledge  of 
the  risk  that  he  thereby  assumes  and  with  the  full  appreciation 
of  the  fact  that  no  form  of  medical  treatment  will  provide  security 
against  an  acute  attack. 


360  -  Appendix 

There  are  circumstances  which  justify  postponement  of  opera- 
tion if  the  patient  be  within  easy  reach  of  a  surgeon  and  under- 
stand the  imjwrtance  of  immediate  operation  in  case  acute  symp- 
toms arise.  In  no  case  should  a  person  who  is  the  subject  of 
chronic  appendicitis  permit  himself  to  be  at  such  a  distance  from  a 
competent  surgeon  that  operation  could  not  be  done  in  the  event 
of  an  acute  attack. 

There  is  no  medical  treatment  of  chronic  appendicitis  aside 
from  the  requirements  of  general  hygiene. 

The  inter\*al  operation  for  appendicitis,  about  which  one  for- 
merly heard  much,  has  been  relegated  to  a  deserved  obli\ion.  The 
term  "interval  operation"  implies  improper  treatment,  since  no 
one,  unless  under  very  exceptional  circumstances,  should  be  allowed 
to  have  more  than  the  first  attack,  as  the  appendix  should  have 
been  removed  early  in  that  attack.  The  idea  of  attempting  to 
carry  a  case  of  acute  appendicitis  through  an  acute  attack  by  medical 
means  in  order  that  the  appendix  may  be  removed  more  safely 
after  the  subsidence  of  acute  sjTnptoms  is  an  absurdity.  In  case 
an  abscess  has  been  present  at  the  time  of  operation  and  the  sur- 
geon has  found  it  impossible  or  imprudent  to  remove  the  appendix  it 
is  proper  and  ad\'isable  to  remove  the  appendix  after  recovery  from 
the  abscess  has  taken  place.  The  appendix  is  rarely  if  ever  com- 
pletely destroyed  during  the  process  of  abscess  formation  and  in 
a  considerable  percentage  of  cases  gives  subsequent  trouble.  In 
this  sense  the  intenal  operation  still  has  a  field  of  usefulness. 

Finally,  it  should  be  remarked  that  any  symptoms  due  to  disease 
of  the  appendix,  however  slight,  are  a  distinct  warning  and  consti- 
tute the  indication  for  appendectomy;  that  medical  treatment  has 
but  an  insignificant  influence  in  warding  off  attacks  as  can  be  under- 
stood by  anyone  who  has  the  least  knowledge  of  the  pathology  of 
the  disease;  that  the  operation  of  simple  appendectomy  has  almost 
no  contraindications  owing  to  the  very  slight  mortality  attached  to 
it;  and  that  the  patient  is  fortunate  to  have  his  disease  begin  in  a 
chronic  rather  than  in  an  acute  form  if  he  fall  into  the  hands  of  an 
enlightened  physician  who  thoroughly  understands  the  possibilities 
and  limitations  of  medical  versus  surgical  treatment  of  appendicitis- 


LIST  OF  NAMES, 


Aboulker,  ii6 

Adami,  148 

Adenot,  28 

Adrian,  75 

Ahrt,  21 

Albers,  23 

Amyand,  14  30 

Anders,  334 

Amick,  203 

Apolant.  75 

AretJeus,  10,  29 

Amaldus  Villanovaniis,  10 

AschofiF,  163 

Ashhurst,  207 

Aufrecht,  139 

Avacenna.  10 

Bagliv-us,  14 

Baillie,  16 

Baldauf,  121 

Barbacd,  150 

Barnard.  342 

Barth,  1 16 

Battle,  282 

Bauhln,  6 

Beger,  123 

Bennet,  181 

Berard.  337 

Berardinone,  188 

Berengarius,  4 

Berry,  42,  64,  157,  162,  sss 

Bertel,  123 

BierhofF.  26 

Birch-Hirshfeld,  165 

Blackadder,  17 

Blake,  52 

Bland-Sutton.  70,  108 

Bloodgood.  79 

Blumer,  69,  197 

Bodey,  19 

Boerhaave.  14,  30 

Boody,  52 


Borst,  123 
Bossard,  96 
Box,  77 
Boyer,  20 
Brazil,  77 
Breuer,  160 
Brewer,  246 
Briquet,  24 
Bristow,  47 
Br>ant,  43 
Buck,  35 
Bull.  138 
Burkhardt,  123 
Bume,  22 

Cabot,  A.  T.,  123 
Canal,  67 
Celsus,  9,  10 
Chappie,  223 
Chaput,  37 
Chassaigjiac,  35 
Clado,  9,  39 
Cless,  25 
Coats,  108 
Coe,  72 
Copeland,  16 
Copland,  20 
Corbin,  23 
Comer,  248 
Crellius,  15 
Crile,  205 
Cushing,  202 
Czemy,  115 

Dalmer,  96 

Dance,  18 

Davis,  37 

Dawbam,  37,  289 

Day,  118 

Deaver,  H.  C,  196,  231 

Deaver,  J.  B.,  37,  78,  107 

Dennis,  197 


361 


362 


List  of  Names 


Dietrich,  123 
Dieulafoy,  173,  234 
Dixon,  197 
Dodwell,  113 
Dudgeon,  152 
Dun,  197,  221 
Dupuytren,  20 
Durand,  58 

Edebohls,  39,  165,  238 
Edington,  123 
Einhorn,  70,  138 
Elliot,  37 
Erastus,  12,  13 
Ewald,  103 

Fabricius  ab  Aquapendente,  7 

Fabricius  Hildanus,  12 

Fallopius,  6 

Fenwick,  108,  113 

Fernelius,  11 

Ferrall,  19 

Finney,  77,  202 

Fitz,  26,  202 

Fowler,  Geo.  R.,  38,  159 

Fowler,  R.  S.,  38 

Fox,  26 

Fraenkel,  108 

Franke,  74,  221 

Frankfurter,  132 

Frazier,  173 

V.  Frisch,  146 

Galen,  i,  10 
Garmanns,  15 
Gaut,  334 
Gerlach,  9,  54 
Gerster,  339 
Gibson,  255 
Goetjes,  123 
Goldbeck,  19 
Goluboff,  174 
Goodhart,  76 
Gouillioud,  28 
Goyens,  197 
Grant,  76 
Green,  203 
GriU,  114 
GrisoUe,  23 


Guinon,  248 
Guttman,  108 

Haedeus,  115 
Haig,  77 
Haller,  8,  16 
Hallo  well,  23 
Hamburger,  77 
Hammond,  L.  J.,  202 
Hancock,  ^^ 
Harte,  117,  207 
Hawkins,  103,  108,  158 
Head,  181 
Heister,  15 
Helmont,  13,  29 
Herlin,  16 
Hermes,  70 
Hildebrandt,  185 
Hilton,  214 
Hinglais,  114 
Hippocrates,  9 
Hoefer,  67 
HofiFacker,  21 
Holden,  43 
Homans,  35 
Hoffenhausen,  201 
Hornung,  23 
Husson,  18 
Hyde,  152 

Iliff,  19 

Jacobson,  77 
Jadelot,  16 
Jalaguier,  282 
Jobert,  18 
Jones,  122,  339,  344 
Jopson,  loi 
Josue,  173 

Kahn,  184 

Kammerer,  282 

Karrenstein,  72 

Keen,  96 

Keetley,  334 

Kehr,  234 

Keith,  67 

Kelly,  116,  117 

Kelynack,  75,  103,  108,  157 


List  of  Names 


363 


Klecki,  174 
Krafft,  138,  156 
Kraussold,  103 
Kretz,  75 
Kronlein,  35 
Kummel,  132 

Lack,  157,  163 

Lafforgue,  116 

de  Lamotte,  16 

Lane,  222 

Langheld,  138 

Lanz,  150 

Laurentius,  6 

Le  Conte,  123 

Leichtenstern,  146 

Lejars,  121 

Lennander,  132 

Letulle,  86 

Leube,  107 

Leudet,  25 

Lewis,  34 

Lieberkuhn,  8 

Lockwood,  9,  54,  61 

Louyer-Willermay,  17,  21 

Lowe,  Peter,  12 

McBurney,  27,  37 
MacCarty,  118 
McCosh,  196,  221 
MacEwen,  67,  316 
McGrath,  118 
Mackenzie,  61 
McRae,  70 

McWilliams,  117,  122,  223 
Malespine,  24 
Mangoldt,  189 
Manley,  69 
Mannaberg,  189 
Marvel,  75 
Maschowitz,  119 
Mathes,  221 
Matterstock,  26 
Maunsell,  193 
Mayer,  76 
Mayo,  38 
Melier,  18 
V.  Merling,  21 
Mestivier,  15,  32 


Metchnikoff,  67 

Mikulicz,  140 

Milner,  118,  123 

Monks,  52 

Morgagni,  7 

Morton,  T.  G.,  36 

Mounier,  116 

Morris,  224 

Moylan,  P.  F.,  345 

Moynihan,  38,  225 

Moxon,  26 

Miinchmeyer,  35 

Muscatello,  56 

Murphy,  115,  210,  214,  254 

Mannings,  156 

Navratil,  127 
Neilson,  251 
Neugobauer,  108 
Noeggerath,  86 
Nothnagel,  103 
Noyes,  35 

Oberndorfer,  118 
Ochsner,  38,  183 
Oppolzer,  25 
Oribasius,  10 
Ormerod,  25 
Orth,  123 

Page,  108 
Paget,  345 
Par6,  4 

Parker,  Willard,  34 
Parkinson,  16 
Partsch,  116 
Paterson,  328 
Paulier,  138 
Paulus,  Simon,  11 
Paviot,  77 
Pedrini,  29 
Pellegrini,  339 
Pepper,  Wm.,  26 
Perrone,  201 
Petrequin,  20,  23 
Pevvel,  337 
Pieron,  21 
Piersol,  162 
Pilcher,  96 


364 


List  of  Names 


Polya,  127 

V.  Pommer-Esche,  23 
Ponceau,  18 
Poynter,  77 
Prescott,  17 

Rammstadt,  79 

Reich  el,  184 

Renvers,  132 

Rhea,  118 

Ribbert,  157,  162 

Richardson,  186 

Riedel,  198,  234 

Riverius,  30 

Robinson,  Byron,  52,  70,  164 

Robson,  38,  225 

Roberts,  John  B.,  203 

Rodman,  334 

Roger,  173 

Rogers,  232 

Rokitansky,  24 

Rolleston,  9,  61,  122,  181,  248 

Rostowzen,  75 

Roussel,  13 

Roux,  132,  173 

Rowntree,  115 

Ruhrah,  114 

Russ,  3S3 

Ruyschius,  14 

Sabatier,  8 
Sahli,  157 
Sailer,  316 
Sands,  36 
Santorini,  8,  14 
Saracenus,  12 
Sargeant,  152 
Schede,  126 
Schelbenzuber,  337 
SchoUer,  165 
Schrumpf,  116 
Schiiller,  36 
Senn,  28,  iii 
Shaw,  69,  197 
Sherren,  59,  181 
Singer,  223,  234 
Sonnenberg,  70,  78,  138 
Sprengel,  37 
Stengel,  108 


Stephanus,  4 
Sternberg,  123 
Stokes,  203 
Sutherland,  76 
Swallow,  108 
Sydenham,  13,  30 
Symonds,  18,  35 

Tait,  36 

Talamon,  70,  83 
Tavel,  150 
Tiedemann,  21 
Tietze,  144 
Toft,  103 
Treitz,  9 
Treves,  36,  108 
Tripier,  77 
Tulpius,  6 
Tuttle,  333 

van  Cott,  159 
Vassmer,  118 
Verheyen,  7 
Vesalius,  4 
Vidus  Vidius,  6 
Virchow,  107 
Voeckler,  121,  123 
Volz,  25,  168 
Vosse,  8 

Waldron,  19 
Wallace,  77 
Walther,  25 
Waring,  115 
Warthin,  119,  122 
Weber,  76 
Wedels,  15 
Wegeler,  17 
Weir,  35,  108,  123 
Weitbrecht,  8 
Welch,  150 
Werth,  108 
Whipham,  123 
White,  123 
Whitmore,  333 
Wickham,  18 
Wilks,  26 
Willis,  14 
Willy  Meyer,  333 
Wilms,  316 


List  of  Names  365 

With,  26  Yeo,  77 

Wood,  67 

Woolsey,  43  Zacutus  Lusitanicus,  29 

Wright,  124  Zuckerhandl,  162 


INDEX. 


Abdominal  belts,  313 
supporters,  313 
tonsil,  42 
wall,  abscess,  345 
Abscess,  abdominal  wall,  345 
after-treatment,  330 
appendicular,  89 
follicular.  90 
in  children,  98 
interstitial,  89 
diagnosis,  215 
diffuse,  136 
hepatic,  139,  236 
kidney,  139,  239 
liver,  139,  236 
omentum,  302 
operation  for,  290 
ovarian,  245 
para-tjT)hlitic,  136 
peri-appendicular,  133,  289 
absorption,  139 
position,  135,  289 
rupture,  138 
sequels,  139 
peri-hepatic,  236 
peri-renal,  137,  242 
peri-typhlitic,  133 
properitoneal,  312 
pulmonary,  137,  139 
retroperitoneal,  96,  137 
secondary,  300 
spleen,  139 
stitch,  313 

subdiaphragmatic,  137,  342 
subphrenic,  137,  342 
Absence  of  appendix,  42 
Actinomycosis  in  appendicitis,  78, 
Adhesions,  peritoneal,  144 
post-operative,  316 
treatment,  317 
Etiological  factors,  actinomycosis, 
age,  69 
table,  71 


114 


7^ 


Etiological  factors,  bacteria,  146 

blood  supply  of  appendix,  159 

calculi,  165 

chemical  irritation,  164 

chicken-pox,  77 

concretions,  165 

constipation,  73 

disturbance  of  digestion,  77 

drainage  of  appendix,  153,  155 

dysentery,  74 

enterozoa,  165 

exciting  causes,  164 

exposure  to  weather,  78 

foreign  bodies,  165 

gastro-enteritis,  73 

Gerlach's  valve,  156 

influenza,  75 

intestinal  parasites,  79 

involution  of  appendix,  162 

length  of  appendix,  156 

lymphoid  tissue,  157 

measles,  77 

meso-appendix,  155 

mixed  infection,  150 

nationality,  72 

predisposing  causes,  155 

previous  attacks,  77 

purpura  haemorrhagica,  77 

recapitulation,  170 

rheumatism,  76 

scarlet  fever,  77 

season,  73 
table,  71 

sex,  70 
table,  71 

staphylococci,  152 

streptococci,  152 

stricture  of  appendix,  157 

tonsillitis,  75 

traumatism,  78,  164 

tuberculosis,  78 

typhoid  fever,  74 
After-treatment,  323  (vide  Operation) 


367 


368 


Index 


Age  in  appendicitis,  69 

table,  71 
Amputation  of  appendix,  spontaneous, 

100 
Anaesthesia,  279 
Anaesthetic,  279 
Anaesthetist,  280 
Anatomy,  41 

comparative,  42 
Angina  of  appendix,  157 
Anodynes  in  treatment,  273 
Apophysitis,  27 
Appendicitis,  acute,  81,  83 
bacteria,  table,  147 
calculi,  table,  166 
catarrhal,  81,  83 
macroscopy,  84 
microscopy,  85 
diagnosis,  209 
gangrenous,  81,  99 
macroscopy,  99 
microscopy,  loi 
interstitial,  81,  87 
macroscopy,  90 
microscopy,  88 
pain,  176 

reflex  symptoms,  182 
rigidity  of  muscles,  1 79 
symptomatology,  175 
symptoms,  176 
tenderness,  179 
three  cardinal  symptoms,  1 76 
treatment,  264 
ulcerative,  81,  92 
macroscopy,  92 
microscopy,  97 
varieties,  81 
aetiological  factors,   actinomycosis, 
78 
age,  69 

table,  71 
bacteria,  146 

blood  supply  of  appendix,  159 
calculi,  165 

chemical  irritation,  164 
chicken-pox,  77 
concretions,  165 
constipation,  73 
disturbance  of  digestion,  77 


Appendicitis,  aetiological  factors,  drain- 
age of  appendix,  153,  155 

dysentery,  74 

enterozoa,  165 

exciting  causes,  164 

exposure  to  weather,  78 

foreign  bodies,  165 

gastro-enteritis,  73 

Gerlach's  valve,  156 

influenza,  75 

intestinal  parasites,  79 

involution  of  appendix,  162 

length  of  appendix,  156 

lymphoid  tissue,  157 

measles,  77 

meso-appendix,  155 

mixed  infection,  150 

nationality,  72 

predisposing  causes,  155 

previous  attacks,  77 

purpura  haemorrhagica,  77 

recapitulation,  170 

rheumatism,  76 

scarlet  fever,  77 

seasons,  73 
table,  71 

sex,  70 
table,  71 

staphylococci,  152 

streptococci,  152 

stricture  of  appendix,  157 

tonsillitis,  75 

traumatism,  78 

tuberculosis,  78 

typhoid  fever,  74 
aetiology,  69 
bacteria,  80 
bacteriology,  146 
blood  changes,  252 
carcinoma,  119 
catarrhal,  haemorrhagic,  85 

purulent,  85 
chronic,  81,  189 

bacteria,  table,  147 

catarrhal,  81,  104 
macroscopy,  104 

■     microscopy,  105 

diagnosis,  191 

indigestion,  193 


Index 


369 


Appendicitis,  chronic,  interstitial,  81, 105 
macroscopy,  105 
microscopy,  109 

obliterating,  81,  iii 
macroscopy,  iii 
microscopy,  112 

pain,  193 

pathology,  102 

position  of  appendix,  192 

symptomless,  193 

symptoms,  190 
referred,  193 

treatment,  195 

varieties,  81 
classification,  80 

pathologico-anatomical,  81 
constipation  in,  335 
complications,  335 

abscess,  abdominal  wall,  345 

hepatic,  338 

lung,  343 

pancreas,  336 

peri-appendicular,  341 

subdiaphragmatic,  342 

arteritis,  337 

colitis,  346 

diseases  of  female  genitalia,  349 

empyema,  343 

hernia,  347 

necrosis  of  intestines,  336 
vessels,  337 

obstruction  of  intestine,  346 

parotitis,  344 

perforation,  337 

peritonitis,  335 

phlebitis,  337 

pleurisy,  343 

pneumonia,  344 

post-operative,  table,  351 

pregnancy,  350 

pyemia,  344 

pylephlebitis,  338 

pyoptysis,  341 

thrombosis,  337 

tuberculosis,  348 

venous,  337 
diagnosis,  209 
earliest  case,  12 
exciting  causes,  69,  77,  164 

24 


Appendicitis,  "frozen  out,"  271 
fulminating,  100 
gangrenous,  99 
history,  i 

hysterical  mimicry,  103 
in  children,  196 

abscess,  198 

aetiology,  197 

concretions,  198 

differential  diagnosis,  199 
in  children,  fever,  198 

gangrenous,  198 

pain,  198 

pathology,  197 

perforation,  198 

prognosis,  200 

rigidity,  198 

sex,  197 

symptomatology,  198 

tenderness,  198 

treatment,  200 
infective,  82 
interstitial,  88 
iodine  reaction,  257 
larvata,  103 
leucocytosis,  252 

table,  256 
mild,  82 

obliterating,  107,  in 
operation,  after  treatment,  323 
pain,  referred,  59 
pathogenesis,  69,  154 
pathology,  80 
perforating,  82 
predisposing  causes,  69 
prenatal,  69 
prognosis,  258 
recurrent,  191 
recurring,  82,  105 
relapsing,  82,  105,  190 
sequels,  335  (vide  complications), 
simple,  82 
treatment,  history,  28 

post-operative,  323 
typhoid,  97,  201 

diagnosis,  202,  203 
differential,  204 

intestinal  haemorrhage,  206 
perforation,  205 


370 


Index 


Appendicitis,  typhoid,  prognosis,  206 

symptoms,  204 

treatment,  207 
urine,  237 
Appendicostomy,  333 
Appendicular  abscess,  89 

follicular,  90 

in  children,  98 

interstitial,  89 
colic,  167 
dyspepsia,  193 
Appendiculo-ovarian  ligament,  47,  58 
Appendix,  abscess,  follicular,  90 

interstitial,  89 
absence  of,  42 
actinomycosis,  114 
anatomy,  41 

history,  4 
angina,  157 
blood  supply,  56 
caecal  attachment,  43 
calculi,  95 
carcinoma,  117 

age,  118 

benignancy,  121 

location,  120 

malignancy,  121 

sex,  120 

with  appendicitis,  119 
coats,  54 

colloid  degeneration,  107 
concretions,  95 
cysts  of,  67 
cystic  dilatation,  107 
diameter,  43 
diverticula,  108 
embryology,  41 
empyema,  91 
endothelioma,  123 
fibro- myoma,  116 
functions,  66 
gangrene,  58,  99 
hiatus  muscularis,  55 
histology,  54 
hydatid  cyst,  116 
hydrops,  107 
intussusception,  248 
length,  43 
lesions  of,  83 


Appendix,  lipoma,  116 
lymph-adenoma,  116 
lymphatics,  58 
lymph  gland,  58 
lymphoid  tissue,  66 
lympho-sarcoma,  124 
mucocele,  107 
mucous  membrane,  54 
muscular  coat,  55 
myoma,  116 
myxo-sarcoma,  126 
nerves  of,  59 
perforation  of,  58,  93,  95 
peritoneal  coat,  55 
poljqi,  116 
position,  45,  47 

table,  53 
pseudo-cyst,  108 
purulent  infiltration,  89 
retention  cyst,  107 
sarcoma,  124 
sloughing,  100 

spontaneous  amputation,  100 
sub  mucosa,  55 
suppuration,  89 
tuberculosis,  113 
tumors,  116 
valve,  54 
veins,  58 

Bacillus  capsulatus,  152 

coli  communis,  148 

enteritidis,  148 

fusiformis,  152 

lactis  aerogenes,  148 

neapolitanus,  148 

proteus,  152 

pyocyaneus,  152 
in  abscess,  135 

pyogenes  foetidus,  148 

subtilis,  152 
Bacteria  as  aetiological  factor,  146 

colon  group,  148 

in  appendicitis,  80 

in  peritonitis,  128 

table  of,  147 
Bacteriology  of  appendicitis,  146 
Bacterium  coli  commune,  148 

as  a  group,  149 


Index 


371 


Bacterium  coli  commune,  virulence,  149 
Battle's  incision,  37 
Belt,  abdominal,  313 
Biliary  ducts,  diseases,  234 
Bimucous  fistula,  96 
Bladder  symptoms  in  appendicitis,  183 
Blood  changes  in  appendicitis,  252 
Bowel  necrosis,  336 

Caecal  vein,  58 

Caecum,  carcinoma  of,  227 

development,  42 

distention,  223 

embryology,  41 

gangrene,  299 

in  inguinal  hernia,  45 

intestinum  posterium,  6 

location,  41 

malignant  disease,  227 

mobile,  315 

of  Galen,  6 

peritoneal  covering,  43 

tuberculosis,  227,  232 

types,  42 
Calculi,  appendicular,  in  children,  198 

in  appendicitis,  166 
Calculus  of  appendix,  95 

renal,  240 

ureteral,  192,  240 
Carcinoma  of  appendix,  117 
age  in,  118 
benignancy,  121 
location,  120 
malignancy,  121 
sex,  120 

cfficum,  227 
Catarrhal  appendicitis,  acute,  8$ 

chronic,  104 
Chicken-pox  in  appendicitis,  77 
Children,  appendicitis  in,  196 
Chills  in  appendicitis,  184 
Cholecystitis,  235 

gangrenous,  235 

phlegmonous,  235 
Cholelithiasis,  236 
Cigarette  drain,  292 
Clado's  ligament,  47 

point,  179 
Coccus  conglomeratus,  152 


Colica  dextra  artery,  56 
"Colic  passion,"  9 
Colitis,  221,  346 

Colloid  degeneration  of  appendix,  107 
Colon,  ulcer,  perforation,  228 
Concretions  of  appendix,  95 
Constipation  in  appendicitis,  73,  182 
Cyst  of  appendix,  67 

ovarian,  246 
Cystic  dilatation  of  appendix,  107 

Davis  incision,  37 
Dawbarn's  purse-string  suture,  37 
Deaver's  incision,  37 
Diagnosis,  abscess,  215 

appendicitis,  acute,  209 
chronic,  191 
t5TDhoid,  203 

chills,  218 

distention,  215 

fever,  214 

gangrene,  216 

leucocytes,  216 

opium,  210 

pain,  210,  217 

rigidity,  213 

serum,  216 

summary,  216 

'  tenderness,  212 

three  cardinal  symptoms,  209 

vomiting,  212 
Diaphragmatic  pleurisy,  200 
Diarrhoea  in  acute  appendicitis,  182 
Differential  diagnosis,  219 

abscess,  hepatic,  236 
kidney,  239 
ovarian,  245 
peri-hepatic,  236 
peri-nephric,  242 

affections  of  gall-bladder,  206 

biliary  duct  disease,  234 

calculus,  renal,  240 
ureteral,  240 

carcinoma,  caecum,  227 

cholecystitis,  235 

cholelithiasis,  236 

colitis,  221 

cyst,  ovarian,  246 

diaphragmatic  pleurisy,  200 


372 


Index 


Differential  diagnosis,  diverticulitis,  227 
dysentery,  221 
dysmenorrhoea,  244 
empyema,  gaU-bladder,  235 
enteralgia,  220 
enteritis,  acute,  220 
enterospasm,  222 
floating  kidney,  241 
gall-bladder  disease,  234 
gastritis,  acute,  220 
gastro-duodenal  catarrh,  220 
gastro-enteritis,  199 
gastro-intestinal  inflammation,  219 
in  children,  199 
intestinal  colic,  220 

haemorrhage,  206 

obstruction,  226 

perforation,  205 

stasis,  222 
intussusception,  199 
kidney  disease,  239 
menopause,  244 
movable  kidney,  238 
nephritis,  toxic,  241 
oophoritis,  245 
pancreatitis,  acute,  236 

chronic,  237 
pelvic  disease,  195 
pleurisy,  247 
pneumonia,  200,  247 
pregnancy,  extra-uterine,  243 
pylorospasm,  194 
pyonephrosis,  239 
pyosalpinx,  245 
renal  colic,  240 
salpingitis,  244 
sarcoma  of  caecum,  231 
secretory  neuroses,  194 
summary,  195 
thrombosis,  femoral  vein,  206 

iliac  vein,  206 
torsion  of  omentum,  247 
tuberculosis  of  caecum,  227,  232 

ileum,  232 

mesenteric  glands,  232 
typhlitis,  223 
typhoid,  204,  232 

perforation,  205 


Differential     diagnosis,     ulcer,     gastro- 
intestinal, perforated,  224 
of  colon,  perforated,  228 
of  duodenum,  224 
perforated,  225 
of  stomach,  224 
perforated,  225 
upper  abdominal  disease,  193 
ureter,  affections  of,  239 
ureteritis,  240 
Distention,  general,  217 
localized,  217 
in  appendicitis,  acute,  186 
Diverticulitis,  227 
Diverticulum  of  appendix,  108 
Drainage,  post-operative,  291,  320 
Dysentery  in  appendicitis,  74,  221 
Dysmenorrhoea,  244 
Dyspepsia,  appendicular,  193 

Ecphyaditis,  27 
Edebohl's  incision,  37 
Eliot's  incision,  37 
Empyema,  343 

of  appendix,  91 

of  gall-bladder,  235 
Endothelioma  of  appendix,  1 23 
Enemas,  273 

Enteric  fever,  232;  vide  typhoid  fever 
Enteritis,  acute,  220 
Enteroclysis,  271,  327 

method  of  administration,  272 
Enterospasm,  222 
Epi typhlitis,  27 

Exciting  causes  of  appendicitis,  69,  77, 
164 

Femoral  vein,  thrombosis,  139 
Fever  as  a  symptom,  183 

in  children,  198 
Fibro- myoma  of  appendix,  116 
Fistula,  appendicular,  305,  334 
treatment,  310 
bimucous,  96 
faecal,  305 
external,  306 

treatment,  310 
internal,  309 
operation,  311 


Index 


373 


Fistula,  faecal,  symptoms,  310 

simple,  311 
Foreign  bodies  in  appendix,  165 
Fossa,  ileo-caecal,  61,  64 
inferior,  64 
superior,  64 

ileo-colic,  61 

peri-cajcal,  64 

retro-colic,  64 

sub-cffical,  64 
Fossae,  peritoneal,  61 
Fowler's  position,  38 
Fulminating  appendicitis,  100 

Gagen-Thorn's  incision,  37     • 
Gall-bladder  disease,  234 

empyema  of,  235 
Gangrene  of  appendix,  58,  99 
in  children,  198 

of  caecum,  299 
Gangrenous  appendicitis,  99 
Gastric  dilatation,  prevention  of,  325 

ulcer,  224 

perforated,  225 
Gastritis,  acute,  220 
Gastro-duodenal  catarrh,  220 
Gastro-enteritis,  in  children,  199 

in  appendicitis,  73 
Gerlach's  valve,  156 
"Grid-iron"  incision,  37 
Glass  drainage  tube,  292,  320 

care  of,  332 
Gauze,  coifer-dam,  290 

use  of  in  suppuration,  290 
Gauze-drainage,  291 

removal,  295 

Haemaglobin  in  appendicitis,  252 
Haemorrhagic  peritonitis,  143 
Hancock's  incision,  284 
Harrington's  incision,  37 
Hepatic  abscess,  139,  236 
Hepatitis,  suppurative,  338 
Hernia  as  complication,  347 

post-operative,  313 
operation  for,  314 

prevention  of,  313 

through  meso-appendix,  47 

ventral,  313 


Hiatus  muscularis,  55 
Hiccough  in  appendicitis,  182 
Histology  of  appendix,  54 
History,  i 

abscess   of  appendix,  first  laparot- 
omy, 33 
opened,  32 

operations  for,  33,  34,  35 
peri-appendicular,  first  recovery, 

13 

rupture,  9 

into  bowel,  18 
absence  of  appendix,  21 
adversaria  anatomia,  7 
anatomy  of  appendix,  4 
apophysis,  11 
appendicitis,  earliest  case,  12,  15 

first  case  in  America,  1 7 

obliterans,  28 

pain  in,  13 

suggestion  of  operation,  18 

term  first  used,  27 
appendicula,  11 

removal,  12 
appendix,  bacteriology,  27 

extraction  of  calculus,  18 

first  removal,  30 
interval  removal,  36 

in  hernia,  14 

not  found,  8 

obliterated,  16 

obliteration  of  lumen,  21 

pathology,  21,  26 

pin  in,  31 
birds,  caecum  in,  7 
caecum  of  Galen,  6 
Clado's  hgament,  9 
clinical  cases  of  appendicitis,  9 

data,  9 
colic  passion,  9 

concretions  in  appendix,  8,  16 
ecphyaditis,  27 
epityphlitis,  27 
faecal  impaction,  19 
first  case  of  appendicitis,  15 
in  America,  1 7 

interval  operation,  36 
foreign  bodies  in  appendix,  16,  21 
Fowler  position,  38 


374 


Index 


History,  Gerlach's  valve,  9 

Hippocrates,  cause  of  death,  12 
iliac  passion,  9 
incisions  for  appendicitis,  37 
McBurney's  point,  27 
malignant  tumor  of  caecum,  19 
Murphy  treatment,  38 

of  peritonitis,  38 
Ochsner  treatment,  38 
peri-caecal  fossae,  9 
peritoneal  fossae,  8 
peritonitis  appendicularis,  26 
peri-typhlitis,  23 
phlegmonous  mass  of  caecum,  19 
phlegmons,  extraperitoneal,  25 

intra-peritoneal,  25 
pin  in  appendix,  16 
quince  seed  in  appendix,  1 1 
resume,  39 

retro-caecal  cellulitis,  19 
scolecoiditis,  27 
stercoral  typhlitis,  23 
treatment,  28 

by  application  of  puppy-dog,  30 

by  Boerhaave,  30 

by  bullets,  29 

by  emetics,  29 

by  enemas,  29 

by  horseback  riding,  30 

by  hot  oil  baths,  29 

by  lead  pills,  29 

by  leeches,  3$ 

by  opium,  $s 

by  purgatives,  29 

by  quicksilver,  29 

by  shot,  16 

by  venesection,  28 

first  removal,  30 
tuberculosis  of  appendix,  21,  23 
typhlitis,  chronic,  23 

simple,  23 
valve  of  appendix,  8 
worms  in  appendix,  8 
Hydatid  cyst  of  appendix,  116 
Hydronephrosis,  146 
Hydrops  of  appendix,  107 
Hjqjeralgesia,  cutaneous,  181 
Hyperpyrexia,    in    appendicitis,    acute, 
184 


Icterus  in  appendicitis,  184 
Ileo-caecal  artery,  56 

fold,  61 

fossa,  61,  64 
inferior,  64 
superior,  64 
Ileo-colic  artery,  56 

fold,  61 

fossa,  61 

lymph  glands,  58 

vein,  58 
Iliac  fossa,  blood  supply,  56 

passion,  9 

vein,  thrombosis,  139 

vessels,  necrosis,  337 
Ilio-psoitis,  139 
Incision,  Battle's,  37,  282 

Davis,  37 

Deaver's,  37 

direct,  281 

Edebohl's,  37 

Eliot's,  37 

Gagen-Thorn's,  37 

"grid-iron,"  37,  284 

Hancock's,  284 

Harrington's,  37 

indirect,  281 

Jalaguier's,  37,  282 

Kammerer's,  37,  282 

Lennander's,  37 

McBurney's,  37,  284 

muscle-splitting,  37,  284 

oblique,  285 

rectus  displacement,  283 
splitting,  282 

straight,  37 

Wier's,  37 
Incisional  hernia,  313 
Indigestion  in  appendicitis,  193 
Infection  abdominal  wall,  312 
"Inflammation  of  bowels,"  209 
Influenza  in  appendicitis,  75 
Interstitial  appendicitis,  acute,  87 

chronic,  105 
Interval  operation,  360 
Intestinal  colic,  220 

stasis,  222 

obstruction,  226 
Intestine,  embryology,  41 


Index 


375 


Intestine,  necrosis,  $s^ 

obstruction,  346 
Intussusception  of  appendix,  248 

in  children,  199 
Iodine  reaction,  257 
Irrigation  in  appendicitis,  293 

in  peritonitis,  293 

Jalaguier's  incision,  37,  282 

Kammerer's  incision,  37,  282 
Kidney,  abscess,  139 

diseases,  239 

floating,  241 

movable,  238 

Lane's  kink,  315 
Lavage,  post-operative,  325 
Length  of  appendix,  43 
Lennander's  incision,  37 
Lesions  of  appendix,  83 
Leucocytosis,  252 

in  appendicitis,  acute,  185 

in  diagnosis,  216 

in  prognosis,  256 

table,  256 
Ligament,  appendiculo-ovarian,  47,  58 

of  Clado,  47 
Lipoma  of  appendix,  116 
Liver,  abscess,  139 
Lymph-adenitis,  139 
Lymph-adenoma  of  appendix,  116 
Lymphangitis,  139 
Lymphatics  of  appendix,  58 
Lymph  gland,  appendicular,  58 

ileo-colic,  58 
Lympho-sarcoma  of  appendix,  124 

McBurney's  incision,  37 

point,  27 
Macroscopy,  appendicitis,  acute,  catar- 
rhal, 84 
gangrenous,  99 
interstitial,  88 
ulcerative,  92 
chronic,  catarrhal,  104 
interstitial,  105 
obliterating,  in 
Measles  in  appendicitis,  77 


Medical  treatment,  355 
Menopause,  244 
Menstruation,  painful,  244 
Mesenteric  glands,  232 
Meso-appendix,  45 

in  aetiology,  155 
Microscopy,  appendicitis,  acute,  catar- 
rhal, 85 
gangrenous,  loi 
interstitial,  88 
ulcerative,  97 
catarrhal,  85 
chronic,  catarrhal,  105 
interstitial,  109 
.  obliterative,  112 

Movable  kidney,  238 
Mucocele  of  appendix,  107 
"Muscle-splitting"  incision,  37 
Myoma  of  appendix,  116 
Myxo-sarcoma  of  appendix,  126 

Nationality  in  appendicitis,  72 
Nausea  in  appendicitis,  acute,  182 

post-operative,  325 
Necrosis,  iliac  vessels,  337 

intestine,  336 
Nephritic  colic,  240 
Nephritis,  toxic,  241 
Nerve,  eleventh  dorsal,  59 

first  lumbar,  59 

twelfth  dorsal,  59 
Nerves  of  appendix,  59 
Nutrient  enemas,  328 

Oblique  incision,  285 
Obliterating  appendicitis,  107,  in 
Obstruction,  intestinal,  303,  346 
post-operative,  303 

treatment,  304 
Ochsner's  treatment,  38 
Omentum,  abscess,  302 
Oophoritis,  245 
Operation,  adhesions,  298 
after-treatment,  323 

abdominal  supporters,  313 

lavage,  325 

morphia,  326 

nourishment,  326 

opium,  326 


376 


Index 


Operation,  after-treatment,  posture,  323 

saline,  326 
enemas,  328 
enteroclysis,  327 

special,  329 

stimulants,  325 

urine,  328 
amputation  of  appendix,  287 
anaesthetic,  279 
anaesthetist,  280 
appendicostomy,  3$^ 
cardiac  murmur,  265 
closure  of  abdomen,  318 
complications,  297 

table,  351 
drainage,  291,  292 
examination  of  patient,  277 
fistula,  faecal,  311 
following  peritonitis,  274 
for  abscess,  290 
gangrene  of  caecum,  299 
gauze  cofiFer-dam,  290 
hernia,  post-operative,  314 
incision,  abdominal,  281 

Battle's,  282 

direct,  281 

"gridiron,"  284 

Hancock's,  284 

indirect,  281 

Jalaguier's,  282 

Kammerer's,  282 

McBurney's,  284 

median,  281 

muscle-splitting,  284 

oblique,  285 

rectus  displacement,  283 
splitting,  282 
in  clean  cases,  286 
in  difiFuse  peritonitis,  296 
in  diffusing  peritonitis,  267 
in  renal  disease,  266 
in  suppurative  cases,  289 
interval,  360 
irrigation,  293 
organic  disease,  265 
pain,  post-operative,  315 
peritonitis,  after-treatment,  332 
preparation  of  patient,  277 
renal  sufficiency,  277 


Operation,  sequels,  300 

abscess,  omentum,  302 
properitoneal,  312 
secondary,  300 
stitch,  313 
adhesions,  316 
fistula,  appendicular,  305 

faecal,  305 
hernia,  313 
obstruction,  303 
pain,  315 
pneumonia,  344 
sutures,  319 
technic,  277 
time  for,  266 
treatment  of  stump,  289 
"walling  off,"  291 
wound,  closure,  318 
drainage,  320 
dressing,  320 
Opium  in  after-treatment,  326 
in  treatment,  273 
use  of,  222 
Ovary,  abscess,  245 
cyst,  246 

Pain  as  symptom,  1 76 

at  McBurney's  point,  59 
hepatic,  217 
ileo-caecal,  223 
in  appendicitis,  acute,  176 
secondary,  178 

chrome,  192 
in  children,  198 
in  cicatrix,  317 
in  diagnosis,  210,  217 
initial,  177 
left-sided,  217 
location  of,  178 
post-operative,  315 
recurrence  of,  178 
referred,  178 

explanation  of,  59 

from  appendix,  59 

to  testicle,  59 
reflex,  59 
secondary,  178 
subsidence  of,  178 
Palpation,  187 


Index 


377 


Pancreatitis,  acute,  236 

chronic,  237 
Parasites,  intestinal,  79 
Para-typhlitic  abscess,  136 
Para-typhoid  of  Dieulafoy,  201 
Parotitis,  344 
Pathogenesis  of  appendicitis,   69,    154. 

(Vide  JEtiological  factors.) 
Pathology  of  appendicitis,  80 
acute  interstitial,  90 
chronic,  102 
in  children,  197 
Percussion,  188 
Perforation  during  typhoid,  202 

of  appendix,  58,  93 

of  ulcer,  colic,  228 
duodenal,  225 
gastric,  225 
gastro-intestinal,  224 
Peri-cfecal  fossa,  64 
Peri-hepatitis,  139 
Peri-nephric  abscess,  242 
Peri-renal  abscess,  136 
Peritoneal  adhesions,  144 

fossae,  61 

sepsis,  143 
Peritonitis,  126 

appendicular,  127,  130,  144 

bacteria  in,  128 

circumscribed  purulent,  133 
serous,  130 

clinical  manifestations,  1 29 

consequences  of,  129 

diffuse,  140 
purulent,  136 

fibrinous,  130,  132 

generalized,  140 

haemorrhagic,  143 

intoxication  from,  129 

operation,  after-treatment,  332 

post-operative,  treatment,  324 

progressive  fibrino-purulent,  140 

purulent,  operation,  296 

putrid,  143 

septic,  143 

sero-fibrinous,  130 

suppurative,  141 

therapeutic,  269 

toxic,  129,  143 

typhoid,  207 


Peritoneum,  powers  of  resistance,  127 

Peri-typhlitic  abscess,  133 

Peri-typhlitis,  23 

Phlebitis,  337 

Physiology  of  appendix,  66 

of  caecum,  66 
Pin  in  appendix,  16 
Pleuritis,  139 
Pleurisy,  247,  343 
"Plica  Vascularis,"  58 
Pneumococcus,  152 
Pneumonia,  247,  344 
Polyp  of  appendix,  116 
Portal  Vein,  phlebitis,  139 
Position  of  appendix,  47 
Post-operative  treatment,  323 
Posture  in  appendicitis,  185 

post-operative,  323 
Predisposing  causes  of  appendicitis,  60, 

15s 
Pregnancy  in  appendicitis,  350 

extra-uterine,  243 
Prenatal  appendicitis,  69 
Primary  typhlitis,  209,  223 
Preparation  of  patient,  277 
Prognosis,  258 

in  abscess,  261 

in  chidren,  200 

in  peritonitis,  261 

in  typhoid  appendicitis,  206 

leucocytosis  in,  256 

mild  cases,  259 

opium  in,  260 

recurrent  attacks,  262 

suppurative  cases,  259 

treatment  as  factor,  260 

with  intercurrent  disease,  261 
Pseudo-appendicitis,  223 
Pseudo-cyst  of  appendix,  108 
Pulmonary  abscess,  137,  139 
Pulse  rate  as  symptom,  184 
Purpura  haemorrhagica  in  appendicitis,77 
Purse-string  suture,  37 
Purulent  appendicitis,  85 
Putrid  peritonitis,  143 
Pyelephlebitis,  139 
Pyemia,  344 
Pylorospasm,  194 
Pyonephrosis,  146,  239 
Pyosalpinx,  245 


378 


Index 


Rectus  muscle,  incision  through,  282 

displacement  of,  283 
Recurrence  of  pain,  178 
Recurrent  appendicitis,  191 
Referred  pain,  178 
Reflex,  viscero-muscular,  59 
Relapsing  appendicitis,  82,  105,  190 
Renal  abscess,  139,  239 

colic,  240 
Respiration  as  symptom,  184 
Restlessness  as  symptom,  176 
Retro-colic  fossae,  64 
Retro-peritoneal  abscess,  96,  137 
Rigidity  of  abdominal  muscles,  181 
Rovsing's  symptom,  180 

Salpingitis,  244 

Sarcoma  of  appendix,  124 

of  caecum,  231 
Scarlet  fever  in  appendicitis,  77 
Scolecoiditis,  27 
Season  in  appendicitis,  73 

table,  71 
Sepsis,,  peritoneal,  143 
Septic  peritonitis,  143 
Sequels,  335.     (Vide  complications.) 

of  operation,  300 
Serum  diagnosis,  216 
Sex  in  appendicitis,  69 

table,  70 
Sex  in  carcinoma  of  appendix,  1 20 
Spleen,  abscess  of,  139 
Starvation  treatment,  38 
Stercoral  typhlitis,  23 
Stitch  abscess,  313 
Straight  incision,  37 
Subcaecal  fossa,  64 
Subdiaphragmatic  abscess,  137 
Subperitoneal  veins,  58 
Subsidence  of  pain,  178 
Supporters,  abdominal,  313 
Superior  mesenteric  artery,  56 
Surgical  treatment,  264 
Suture,  purse  string,  37 
Symptomatology,  175 

auscultation,  189 

inspection,  186 

palpation,  187 

percussion,  188 

summary,  195 


Symptoms  of  appendicitis,  acute,  176 

chronic,  192 

in  children,  198 

typhoid,  204 
bladder,  183 
chills,  184 

condition  of  patient,  185 
constipation,  182 
cutaneous  hyperaesthesia,  181 
diarrhoea,  182 
distention,  186 
hiccough,  182 
hyperpyrexia,  184 
icterus,  184 
leucocytosis,  185 
nausea,  182 
pain,  176 

initial,  177 

left-sided,  217 

secondary,  178 
posture,  185 
pulse  rate,  184 
respiration,  185 

rigidity  of  abdominal  muscles,  181 
temperature,  183 
tenderness  on  pressure,  179 
superficial,  181 
three  cardinal,  176 
tumor,  187 
urinary,  185 
vomiting,  182 
Synonyms  for  appendicitis,  27 

Technic  of  operation,  217 
Temperature  in  acute  appendicitis,  183 
Tenderness  on  pressure,  1 79 

decreased,  217 

in  children,  198 

increased,  217 

position  of,  180 

superficial,  181 

with  pus,  217 
Testicle,  pain  in,  29 
"Therapeutic  peritonitis,"  269 
Three  cardinal  symptoms,  176 
Thrombo-phlebitis,  139 
Thrombosis,  femoral  vein,  139 

iliac  vein,  139 
Tonsil,  abdominal,  42,  54 
TonsilUtis  in  appendicitis,  75 


Index 


379 


Torsion  of  omentum,  247 
Toxic  peritonitis,  143 
Trauma  in  appendicitis,  78 
Treatment,  alimentation,  273 

anodynes,  273 

between  attacks,  275 

early  operation,  264 

enteroclysis,  271 

fluids  by  mouth,  270 

food,  270 

ice-bags,  270 

lavage,  270 

medical,  355 

Ochsner's,  38 

of  adhesions,  post-operative,  317 

of  appendicitis,  acute,  264 
chronic,  195 
in  children,  200 
typhoid,  207 

of  fistula,  appendicular,  310 
external,  310 
faecal,  310 
simple,  311 

of  obstruction,  post-operative,  304 

of  peritonitis,  diffuse,  269 

post-operative,  323 

proctoclysis,  271 

purgation,  269 

sitting  posture,  270 

surgical,  264 
Tuberculosis  complicating  appendicitis, 
348 

in  appendicitis,  78 

of  appendix,  113 

of  caecum,  232 

of  ileum,  232 

of  mesenteric  glands,  232 
Tumor  in  appendicitis,  acute,  187 
Tumors  of  appendix,  116 
Typhlatonia,  316 


Typhlitis,  23,  223 

chronic,  23 

primary,  209,  223 

simple,  23 

stercoral,  23 
Typhoid  appendicitis,  97,  201 

diagnosis,  202 

treatment,  207 
Typhoid  fever,  232 

in  appendicitis,  74 

peritonitis,  207 

perforation,  205 

Ulcer,  colon,  perforated,  228 

gastro-intestinal,  perforated,  224 

duodenal,  224 
perforated,  225 

gastric,  224 
perforated,  225 
Ulcerative  appendicitis,  acute,  92 
Ureter,  affections  of,  239 
Ureteritis,  240 
Urine  in  acute  appendicitis,  185 

post-operative,  328 

Valve,  of  appendix,  54 

of  Gerlach,  9,  54,  156 
Vein,  femoral,  thrombosis,  139 

ileo-colic,  58 

subperitoneal,  58 
Veins  of  appendix,  58 
Viscero-muscular  reflex,  59 
Vomiting  in  acute  appendicitis,  182 

post-operative,  325 

Wier's  incision,  37 
Wound,  closure  of,  318 

dressing  of,  320 

suture  of,  314 
Wright's  solution,  320 


university  of  C'Worma,^^ 
SOUTHERN  B^°'°N'^3Vto  *e  .*«'V 


A  000  511  123  2 


3  1970  00892  6369 


CO 


UJ 
CD 


CO 


O 


Deaver,  John  B 
Appendicitis, 


WI  535 

D285a 

1913 


MEDICAL  SCIENCES  LIBRARY 

UNIVERSITY  OF  CALIFORNIA,  IRVINE 

IRVINE,  CALIFORNIA  92664 


>t»I*j*t'j>t»j>t';>!>t»j 


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